Commentary: Soda taxes, obesity, and the shifty behavior of consumers

Rising obesity is a threat to public health, and taxing sugar-sweetened beverages (SSBs) in order to reduce consumption and thus caloric intake could be a viable policy response. But raising the price of SSB calories will raise the quantity demanded of relatively cheaper calories, and net effect on obesity is unclear. I review the evidence on shifting calorie demand and discuss the viability of soda taxes to achieve improvements in public health.     

Smoking initiation among youth: the role of cigarette excise taxes and prices by race/ethnicity and gender

Existing evidence for the role of cigarette excise taxes and prices as significant determinants of youth smoking initiation is mixed. A few studies have considered the possibility that the impact of cigarette taxes and prices might differ by gender or race/ethnicity. In this paper, we address the role of cigarette taxes and prices on youth smoking initiation using the National Longitudinal Survey of Youth 1997 cohort and discrete-time survival methods. We present results overall and by gender, race/ethnicity, and gender by race/ethnicity. We examine initiation over the age range during which youth are most at risk of initiation and over a period in which substantial changes have occurred in tax and price. The result for cigarette excise taxes is small and mixed across alternative specifications, with the effect strongest for black youth. Cigarette prices are more consistently a significant determinant of youth smoking initiation, especially for black youth.     

The effect of taxation and regulation on cigarette smoking: Fresh evidence from Turkey

Enacting Law No 5247 in May 2008, Turkey has initiated crucial anti-tobacco policies in the last decade. This paper aims to reveal on the effect of anti-tobacco policies such as excise taxes and regulations on cigarette smoking. To this aim, I empirically investigate the long-term dynamics of demand for cigarettes in Turkey through the OLS estimation strategy under various scenarios and models. Using monthly and quarterly data that cover the pre- and post- anti-smoking policy periods, I estimate demand elasticities and compare the pre- and post- taxation and regulation terms. The results presented in the paper confirm that taxation and regulation have affected the long-term dynamics of demand for cigarettes. The price and income elasticities of demand for cigarettes are significantly higher than the previous literature on Turkey. Demand elasticities have increased on average in the anti-tobacco policies period.     

Financial protection of patients through compensation of providers: The impact of Health Equity Funds in Cambodia

Public providers have no financial incentive to respect their legal obligation to exempt the poor from user fees. Health Equity Funds (HEFs) aim to make exemptions effective by giving NGOs responsibility for assessing eligibility and compensating providers for lost revenue. We use the geographic spread of HEFs over time in Cambodia to identify their impact on out-of-pocket (OOP) payments. Among households with some OOP payment, HEFs reduce the amount paid by 35%, on average. The effect is larger for households that are poorer and mainly use public health care. Reimbursement of providers through a government operated scheme also reduces household OOP payments but the effect is not as well targeted on the poor. Both compensation models raise household non-medical consumption but have no impact on health-related debt. HEFs reduce the probability of primarily seeking care in the private sector.     

The effect of cigarette taxes on cigarette consumption.

OBJECTIVES: This paper reexamines the work of Meier and Licari in a previous issue of the Journal. METHODS: The impact of excise taxes on cigarette consumption and sales was measured via standard regression analysis. RESULTS: The 1983 federal tax increase is shown to have an anomalous effect on the regression results. When those data are excluded, there is no significant difference between state and federal tax increases. Further investigation suggests that firms raised cigarette prices substantially in the years surrounding the 1983 federal tax increase, which accounts for the relatively large decrease in consumption during this period. CONCLUSIONS: Federal excise taxes per se do not appear to be more effective than state excise taxes in terms of reducing cigarette consumption. The reaction of cigarette firms to government policies appears to be an important determinant of the success of antismoking initiatives.     

The effect of state cigarette tax increases on cigarette sales, 1955 to 1988.

We evaluated the effect of state cigarette tax increases on cigarette sales in the 50 states for the years 1955 to 1988. State cigarette tax increases were associated with an average decline in cigarette consumption of three cigarette packs per capita (about 2.4%). Larger tax increases were associated with larger declines in consumption. Raising state cigarette taxes appears to be an effective public health intervention that can reduce cigarette consumption and its associated health consequences.     

Anatomy of a health scare: education, income and the MMR controversy in the UK

The measles, mumps and rubella (MMR) controversy provides an interesting case where, for a short period of time, research publicized in the media, suggested a potential risk of serious side-effects associated with the vaccine, where there was also a sharp behavioral response from the public, and where the initial information was subsequently overturned. We consider the controversy from the perspective of health inequalities and the assimilation of information, focusing on whether and how vaccine uptake behavior in the wake of the controversy differed among groups of parents by education and income. Using panel data on the variation in the uptake of the MMR, and other childhood immunizations, across local Health Authority areas we find that the uptake rate of the MMR declined faster in areas where a larger fraction of parents had stayed in education past the age of 18 than in areas with less educated parents. We also find that the same areas reduced their relative uptake of other uncontroversial childhood immunizations, suggesting a "spillover" effect. Using a supplementary data source we find evidence of a corresponding positive income effect, indicating that wealthier parents avoided the MMR dilemma by purchasing single vaccines.     

Time is money: outpatient waiting times and health insurance choices of elderly veterans in the United States

Growth in the number of days between an appointment request and the actual appointment reduces demand. Although such waiting times are relatively low in the US, current policy initiatives could cause them to increase. We estimate multiple-equation models of physician utilization and insurance plan choice for Medicare-eligible veterans. We find that a 10% increase in VA waiting times increases demand for Medigap insurance by 5%, implying that a representative patient would be indifferent between waiting an average of 5 more days for VA appointments and paying $300 more in annual premium.     

The effect of cigarette taxes on cigarette consumption, 1955 through 1994.

OBJECTIVES: This study examines the effectiveness of state and federal taxes in reducing the consumption of cigarettes, estimates the impact of government health warnings, and shows how warnings and taxes interact. METHODS: By means of a pooled time-series analysis from 1955 through 1994 with the 50 states as units of analysis, the impact of excise taxes on cigarette consumption for several different models and econometric techniques is assessed. RESULTS: From 1955 through 1994, increases in state taxes were effective in reducing cigarette use. Federal tax increases, however, appear to have been more effective. This difference is partly the result of the "bootlegging" of cigarettes across state lines and the size of the increases in the federal tax. Cigarette consumption also declined when health warning labels were added. CONCLUSIONS: Increases of taxes on cigarettes are associated with declines in the consumption of tobacco. Because of inflation, increased health concerns, and the declining percentage of smokers, however, large reductions in consumption require large tax increases.     

The effects of excise taxes and regulations on cigarette smoking

We estimate a generalized linear model to examine adult and teenage cigarette demand. Out analysis focuses on the extent to which excise taxes and regulations restricting smoking in public places affect cigarette consumption. The adult results indicate that the price elasticity of demand is unstable over time, ranging from 0.06 in 1970 to -0.23 in 1985. These estimates are lower than most found in previous studies. The teenage price elasticity does not differ statistically from the estimates for adults. Additionally, regulations restricting smoking in public places have a significant effect on both adult and teenage cigarette demand.     

The effect of cigarette taxes on smoking among men and women

The literature contains numerous studies that estimate the effect of cigarette taxes on smoking across various population groups. Although the conclusions are split, most US studies find that men are more responsive to cigarette taxes than women. This paper shows that these results are due to the failure to control for state-specific gender gaps in smoking rates that are correlated with cigarette taxes. When gender-specific state fixed effects are included to control for these gaps, the results indicate that women are nearly twice as responsive to cigarette taxes as are men. Since the econometric specification controls for variation in the tax response by household income, it is unlikely to be responsible for the difference.     

Healthy school meals and educational outcomes

This paper provides field evidence on the effects of diet on educational outcomes, exploiting a campaign lead in the UK in 2004, which introduced drastic changes in the meals offered in the schools of one borough - Greenwich - shifting from low-budget processed meals towards healthier options. We evaluate the effect of the campaign on educational outcomes in primary schools using a difference in differences approach; comparing educational outcomes in primary schools (Key Stage 2 outcomes more specifically) before and after the reform, using the neighbouring Local Education Authorities as a control group. We find evidence that educational outcomes did improve significantly in English and Science. We also find that authorised absences - which are most likely linked to illness and health - fell by 14%.     

The impact of minimum legal drinking age laws on alcohol consumption, smoking, and marijuana use: evidence from a regression discontinuity design using exact date of birth

This paper uses a regression discontinuity design to estimate the impact of the minimum legal drinking age laws on alcohol consumption, smoking, and marijuana use among young adults. Using data from the National Longitudinal Survey of Youth (1997 Cohort), we find that granting legal access to alcohol at age 21 leads to an increase in several measures of alcohol consumption, including an up to a 13 percentage point increase in the probability of drinking. Furthermore, this effect is robust under several different parametric and non-parametric models. We also find some evidence that the discrete jump in alcohol consumption at age 21 has negative spillover effects on marijuana use but does not affect the smoking habits of young adults. Our results indicate that although the change in alcohol consumption habits of young adults following their 21st birthday is less severe than previously known, policies that are designed to reduce drinking among young adults may have desirable impacts and can create public health benefits.     

Multi-tier drugs assessment in a decentralised health care system. The Italian case-study

Objective

To investigate the organisation and decision-making processes of regional and local therapeutic committees in Italy, as a case-study of decentralised health care systems.

Methods

A structured questionnaire was designed, validated, and self-administered to respondents. Committee members, prioritisation, assessment process and criteria, and transparency of committees were investigated.

Results

The respondents represent 100% of the 17 regional committees out of 21 regions (in 4 regions there is not any regional formulary), 88% of the 16 hospital networks and 42% of the 183 public hospitals. The assessment process appears fragmented and may take a long time: drugs inclusion into hospital formularies requires two steps in most regions (regional and local assessment). Most of the therapeutic committees are closed to industry and patients associations involvement. Prioritisation in the assessment is mostly driven by disease severity, clinical evidence, and the absence of therapeutic alternatives. Only 13 out of the 17 regional committees have a public application form for drugs inclusion into regional formulary. Regional and local committees (i) often re-assess the clinical evidence already evaluated at central level and (ii) mostly rely on comparative drug unit prices per DDD and drug budget impact. The level of transparency is quite low.

Conclusions

The Italian case-study provides useful insights into an appropriate management of multi-tier drugs assessment, which is particularly complex in decentralised health care systems, but exists also in centralised systems where drugs are assessed by local therapeutic committees. A clear definition of regulatory competences at different levels, a higher collaboration between central, regional and local actors, and increased transparency are necessary to pursue consistency between central policies on price and reimbursement and budget accountability at the regional and local levels.     

Waiting times and socioeconomic status: evidence from England

Waiting times for elective surgery, like hip replacement, are often referred to as an equitable rationing mechanism in publicly-funded healthcare systems because access to care is not based on socioeconomic status. Previous work has established that that this may not be the case and there is evidence of inequality in NHS waiting times favouring patients living in the least deprived neighbourhoods in England. We advance the literature by explaining variations of inequalities in waiting times in England in four different ways. First, we ask whether inequalities are driven by education rather than income. Our analysis shows that education and income deprivation have distinct effects on waiting time. Patients in the first quintile with least deprivation in education wait 9% less than patients in the second quintile and 14% less than patients in the third-to-fifth quintile. Patients in the fourth and fifth most income-deprived quintile wait about 7% longer than patients in the least deprived quintile. Second, we investigate whether inequalities arise "across" hospitals or "within" the hospital. The analysis provides evidence that most inequalities occur within hospitals rather than across hospitals. Moreover, failure to control for hospital fixed effects results in underestimation of the income gradient. Third, we explore whether inequalities arise across the entire waiting time distribution. Inequalities between better educated patients and other patients occur over large part of the waiting time distribution. Moreover we find that the education gradient becomes smaller for very long waiting. Fourth, we investigate whether the gradient may reflect the fact that patients with higher socioeconomic status have a different severity as proxied through a range of types and the number of diagnoses (in addition to age and gender) compared to those with lower socioeconomic status. We find no evidence that differences in severity explain the social gradient in waiting times.     

我国2015年卷烟消费税上调对卷烟零售价格的影响

目的 评估2015年卷烟消费税上调对卷烟零售价的影响。方法 利用2013-2015年10城市开展的烟草价格监测数据,计算卷烟的名义价格和实际价格,描述价格变化趋势。结果 2013-2015年3次均监测到352种卷烟,其中2013、2014年卷烟名义价格未发生显著变化,2015年卷烟消费税上调后,较2014年有286种卷烟价格上涨,10种常见卷烟名义价格相对于2013年涨幅为0.6%～7.4%,但实际价格与2013年相比涨跌不一。结论 2015年卷烟消费税上调可传导至卷烟零售价,但考虑到通货膨胀和购买力等因素,实际价格上涨有限,其对控烟的意义还需进一步评估。     

Cigarette taxes and older adult smoking: evidence from recent large tax increases

While recent evidence casts some doubt, it is generally accepted that the price sensitivity of smoking varies inversely with age. We investigate the responsiveness of older adult smoking using variation from recent historically large cigarette tax increases in the United States. Using data from the Behavioral Risk Factor Surveillance System from 2000 to 2005, we find consistent evidence that higher taxes reduced smoking participation by older adults, especially those who are less educated and live in low-income households. Our findings run contrary to existing evidence which suggests that cessation behavior by older adults is not sensitive to price. Since a large literature suggests smoking cessation even later in life reduces morbidity and increases longevity, our findings may represent substantial gains in health among tax-induced quitters.