State Tobacco Excise Taxes and Adolescent Smoking Behaviors in the United States

1. BRIGHAM AND WOMEN’S HOSPITAL HARVARD MEDICAL SCHOOL State Tobacco Excise Taxes and Adolescent Smoking Behaviors in the United States Carey Conley Thomson, MD, MPH1,2,3,7 Laurie B. Fisher, SM1 Jonathan P. Winickoff, MD, MPH 2,4,7 Graham A. Colditz, MD, DrPH 1,7,8 Carlos A. Camargo, Jr., MD, DrPH 1,5,7 Charles King III, JD, PhD9 A. Lindsay Frazier, MD, MSc1,6,7 Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital1; Tobacco Research and Treatment Center2, Pulmonary and Critical Care Unit, Department of Medicine3, MGH Center for Child and Adolescent Health Policy4, and the Department of Emergency Medicine5, Massachusetts General Hospital; Department of Pediatric Oncology, Dana-Farber Cancer Institute6; Harvard Medical School7; Department of Health Policy and Management and Epidemiology, Harvard School of Public Health8; and Greylock McKinnon Associates9.

2. ABSTRACT OBJECTIVES: To examine the association between state cigarette excise taxes and smoking behaviors among youth in the United States. METHODS: Experimentation (ever-smoking) and established smoking (> 100 cigarettes in a lifetime) were assessed in a cross-sectional sample of 10,981 boy and girl participants of the Growing Up Today Study, ages 12 to 18 in 1999. Logistic regression was used to examine the odds of experimentation and/or established smoking across increasing quartiles of state cigarette excise taxes. RESULTS: State tax levels in 1999 ranged from 2.5 to 100 cents. In a fully controlled model that utilized generalized estimating equations to account for state clustering, and adjusted for age, gender, peer smoking, parental smoking, state poverty level, and possession of tobacco promotional items, the test for trend across increasing levels of tax was significant (p<0.05) for experimentation. The highest quartile of tax (60-100 cents) was significantly associated with lower odds of experimentation (OR 0.79; 95% CI, 0.64-0.98) and appeared protective against established smoking (OR 0.80; 95% CI, 0.49-1.29). CONCLUSIONS: This study demonstrates that higher cigarette excise taxes are associated with decreased experimental smoking among adolescent boys and girls, and may be associated with lower odds of established smoking in this age group. These results support the inclusion of tobacco taxes in state tobacco control programs.

3. BACKGROUND • Raising taxes to increase the price of cigarettes is often cited as a strategy to reduce youth smoking • Reports by the National Cancer Institute (2001) and Surgeon General (2000) conclude that increased price reduces youth smoking • Many states increased cigarette taxes in the late 1990s, allowing for assessments of larger differences in tax levels since the publication of several prior reports

4. OBJECTIVES To examine the association between state cigarette excise taxes and smoking behaviors among boys and girls in the United States

5. METHODS • Experimentation (ever-smoking) and established smoking (> 100 cigarettes in a lifetime) were assessed in a cross-sectional national sample of 10,981 adolescent (aged 12 to 19 in 1999) participants in the Growing Up Today Study. • Generalized estimating equations were used to account for state clustering and to examine the relationship between state cigarette excise taxes (in quartiles) on experimentation and established smoking, while controlling for important confounders.

6. METHODS- Covariates • Individual covariates: • Age (12-18) • Sex • Parental smoking status (at least one parent smokes) • Peer smoking status (most or all of your peers smoke) • Possession of tobacco promotional items (TPI) • State covariates: • % of the state population living at or below the poverty level [not colinear with tax (r = 0.18); income was (r = 0.63)]. • State clustering

7. Table 1. Characteristics of Growing Up Today Study Sample (n=10,981)

8. Table 2. Smoking Behaviors and State Excise Tax Levels in the Growing Up Today Study Sample (n=10,981)

9. Table 3. Smoking and Smoking-Associated Characteristics by Quartiles of Tax

10. Table 4. Odds Ratios of Experimental Smoking by Quartiles of Cigarette Tax

11. Table 5. Odds Ratios of Established Smoking by Quartiles of Cigarette Tax

12. CONCLUSIONS • This study provides updated evidence that higher state cigarette excise tax levels are associated with decreased experimental smoking among adolescent boys and girls, and may be associated with lower odds of established smoking in this age group. • These results support the inclusion of tobacco taxes in state tobacco control programs

13. LIMITATIONS • Cross-Sectional Study • Variables not included in analyses • SES: • Individual level: income, parental education • all children of nurses, so SES effect diminished • Unable to generalize to children of color (93% white) • State level: • Local ordinances on youth access • Most studies show no impact on youth smoking • State and local price differences could impact outcomes differently than tax • Models which included total pack price instead of tax showed no difference in results • Tobacco Control Program funding omitted from these analyses: • Imprecise data in 1999 • highly colinear with tax (r = 0.70) and with state poverty (r =0.63)

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