Tobacco use and household expenditures on food, education, and healthcare in low- and middle-income countries: a multilevel analysis

Crowding out and impoverishing effect of tobacco in Mexico

INTRODUCTION

Tobacco is one of the world's largest preventable causes of premature death, accounting for more than 8 million deaths and costing the global economy US$1.4 trillion each year. Smoking is a global problem with 1.3 billion people using tobacco worldwide, who will face harmful effects on health and on people's current and future financial situations and quality of life.This article aims to be the first study to generate evidence on the effects of smoking on household expenditure and the number of people living under the poverty threshold by studying the crowding out and impoverishing effect in Mexico.

METHODS

Through econometric methods and maximising a household utility function we estimate the crowding out and impoverishing effect of tobacco consumption in México based on household's income and spending survey from 2020.

RESULTS

Spending on tobacco crowds out household spending on other goods and services. In Mexico, spending on tobacco results in decreased spending on essential goods and services, like education and healthcare, and increased spending on harmful goods such as alcoholic beverages. These effects are common across all income levels but are more pronounced in low-income households. When spending on tobacco increases, for example, following regular price increases made by the tobacco industry, the crowding out effect is exacerbated.In addition, smoking has an impoverishing effect on the population. This is because some families find that their remaining income level falls below the poverty line after deducting money spent on tobacco (a concept known as secondary poverty). In Mexico, 909 132 people are left with a disposable income level below the extreme poverty line because of expenditure on tobacco and smoking-related diseases.

CONCLUSIONS

Smoking affects individual health and the finances of households in Mexico, particularly those of low-income people. By increasing tobacco taxes, those who quit smoking increase their quality of life and well-being. However, those who continue to smoke and increase their tobacco spending are affected by a shift in their spending on other goods and services.The increase in tobacco taxes must be accompanied by public policies that help reduce tobacco consumption and compensate the crowding out on goods and services relevant to the development of households.

Impact of tobacco spending on intrahousehold resource allocation in Montenegro

BACKGROUND

The main goal of this study is to estimate the crowding out impact of tobacco expenditures on the household budget allocation to other mutually exclusive commodity groups in Montenegro.

METHODOLOGY

The analysis uses the Household Budget Survey data from 2005 to 2017 to estimate a system of Engel curves using a three-stage least squares approach. As the tobacco expenditure variable is endogenous to budget shares on other consumption items, instrumental variables were included to obtain consistent estimates.

RESULTS

Overall, the results confirm the existence of the crowding out effect of tobacco spending on various commodities, such as some food items (eg, cereals, fruits and vegetables and dairy products), clothing, housing and utilities, education and recreation while a positive effect of tobacco consumption was estimated on budget shares on bars and restaurants, alcohol, coffee and sugary drinks. These results are consistent throughout the income groups of households. The estimates indicate that an increase in tobacco expenditures leads to reduction in budget shares on essential goods, which is likely to have negative impacts on the household living standard.

CONCLUSIONS

Tobacco expenditure crowds out household spending on necessities, especially in case of the poorest households, thus increasing inequality, hampering human capital development and potentially causing long-term adverse effects on the households in Montenegro. Our results are similar to evidence from other low and middle-income countries. This paper contributes to the analysis of the crowding out effect of tobacco consumption, which was conducted for the first time in Montenegro.

Spatial spillovers of violent conflict amplify the impacts of climate variability on malaria risk in sub-Saharan Africa

Africa carries a disproportionately high share of the global malaria burden, accounting for 94% of malaria cases and deaths worldwide in 2019. It is also a politically unstable region and the most vulnerable continent to climate change in recent decades. Knowledge about the modifying impacts of violent conflict on climate-malaria relationships remains limited. Here, we quantify the associations between violent conflict, climate variability, and malaria risk in sub-Saharan Africa using health surveys from 128,326 individuals, historical climate data, and 17,429 recorded violent conflicts from 2006 to 2017. We observe that spatial spillovers of violent conflict (SSVCs) have spatially distant effects on malaria risk. Malaria risk induced by SSVCs within 50 to 100 km from the households gradually increases from 0.1% (not significant, P>0.05) to 6.5% (95% CI: 0 to 13.0%). SSVCs significantly promote malaria risk within the average 20.1 to 26.9 °C range. At the 12-mo mean temperature of 22.5 °C, conflict deaths have the largest impact on malaria risk, with an approximately 5.8% increase (95% CI: 1.0 to 11.0%). Additionally, a pronounced association between SSVCs and malaria risk exists in the regions with 9.2 wet days per month. The results reveal that SSVCs increase population exposure to harsh environments, amplifying the effect of warm temperature and persistent precipitation on malaria transmission. Violent conflict therefore poses a substantial barrier to mosquito control and malaria elimination efforts in sub-Saharan Africa. Our findings support effective targeting of treatment programs and vector control activities in conflict-affected regions with a high malaria risk.

The Crowding-out Effect of Tobacco Expenditure on Health Expenditure: Evidence From a Lower-Middle-Income Country

INTRODUCTION

Poor people have remarkably lower health expenditures than rich people in Vietnam. According to the 2016 Vietnam Household Living Standard Survey (VHLSS), per capita health expenditure of the top quintile households is around 6 times higher than that of the bottom quintile households.

AIMS AND METHODS

We analyze economic inequalities in health expenditure using the concentration index approach and data from the VHLSS 2010-2016. Next, we use the instrumental-variable regression analysis to examine the crowding-out effect of tobacco expenditure on health expenditure. Finally, we use decomposition analysis to explore whether economic inequality in tobacco expenditure is associated with an economic inequality in health expenditure.

RESULTS

We find a crowding-out effect of tobacco expenditure on health expenditure of households. The share of health expenditure of households with tobacco spending is 0.78% lower than that of households without tobacco spending. It is estimated that a one-VND increase in tobacco expenditure results in a 0.18 Vietnamese Dong (VND) (95% CI: -0.30 to -0.06) decrease in health expenditure. There is a negative association between economic inequality in tobacco expenditure and economic inequality in health expenditure. This means that if the poor consume less tobacco, their expenditure on health can be increased, resulting in a decrease in inequality in health expenditure.

CONCLUSIONS

Findings from this study suggest that reducing tobacco expenditure could improve health care of the poor and reduce inequality in health care in Vietnam. Our study recommends that the government continuously increase the tobacco tax in order to effectively reduce tobacco consumption.

IMPLICATIONS

Empirical studies show mixed results on the effect of tobacco expenditure on health expenditure. We find a crowding-out effect of tobacco expenditure on health expenditure of poor households in Vietnam. It implies that if the poor reduce their expenditure on tobacco, economic inequality in health expenditure can be reduced. Our findings suggest that reducing tobacco consumption in poor households can increase their health expenditure, therefore, decreasing inequality in health expenditure. Different policies to reduce tobacco consumption such as tobacco taxation, smoke-free areas, and tobacco advertisement bans should be strengthened.

Predisposing, Reinforcing, and Enabling Factors of Nicotine Dependence Among Young Adults in a Rural Community

OBJECTIVES

The aim of this study was to determine the influence of predisposing, reinforcing, and enabling factors of nicotine dependence among young adults in a rural community.

STUDY DESIGN

A quantitative, predictive-correlational cross-sectional study was done among 190 young adults in a rural community utilizing compact segmental sampling.

METHODS

Data were collected from August to October 2018 utilizing a validated robotfoto, adapted determinants of smoking questionnaire, and Fagerström test to assess nicotine dependence. Stepwise multiple linear regression was used in predicting the relationship between the predictors and nicotine dependence.

RESULTS

Reinforcing and enabling factors influenced nicotine dependency. The influence of other relatives (β = .179, p = .023) and radio advertisements (β = -.224, p = .008) as well as availability (access) to cigarettes (β = .228, p = .003) were significant predictors of nicotine dependency in the rural community.

CONCLUSION

Identified predictors can help form policies that can help address the availability of cigarettes and advertisements (radio) that can influence nicotine dependence among young adults in a rural community. Furthermore, the influence of other relatives (extended family) can be a factor that can increase the development of nicotine dependence.

Health promoting and demoting consumption: What accounts for budget share differentials by ethnicity in New Zealand

Background

Health demoting consumption of alcohol and tobacco are some of the most important risk factors for health loss worldwide, however there is limited information on these consumption risk factors in New Zealand (NZ) and whether inequities in the risk factors are ethnically patterned.

Methods

We used three nationally representative Household Economic Survey waves (2006/07, 2009/10, 2012/13) (n = 9030) in NZ to examine household expenditure for key health risk-related components of consumption by ethnicity, and its contributors to the differences using non-parametric, parametric and decomposition methods.

Results

Māori households (NZ indigenous population) were significantly poorer (25% less) than non-Māori households in terms of household per capita expenditure. However, our various econometric estimations suggested that, in relative terms, Māori spent more on tobacco and alcohol, and less on healthcare. The gaps become larger at upper quantiles of the budget share distributions; the composition effect (the gap due to differences in individual and household characteristics between Māori and non-Māori) explains most of the tobacco and alcohol budget share gap between the two groups, and less for healthcare. The structure effect (the gap due to returns to/or effect of individual and household characteristics) contributes very little to the budget share gap for tobacco and drink, but increasingly and predominantly when moving along the distribution of healthcare budget share.

The differences between Māori and non-Māori in household ownership, education, and income negatively affect budget share on these health demoting consumption (tobacco and alcohol). The household head's age, education, and employment contributed most to the structure effect.

Conclusions

Our study suggested ethnic inequities in the health risk consumption behaviour are evidenced in NZ. Interventions targeting education and employment that significantly affect household budget shares on risk factors (i.e., harmful consumption) for health loss may help narrow the gaps.

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Alcohol and tobacco are important risk factors for health loss worldwide.

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National Household Economic Survey data were analysed by ethnicity for New Zealand.

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Māori households spent more on tobacco and alcoholic drinks, and less on healthcare.

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The gap due to differences in household characteristics explains most of the budget share gap.

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Interventions targeting education and employment may help narrow the gaps.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

Implications of household tobacco and alcohol use on child health and women's welfare in six low and middle-income countries: An analysis from a gender perspective

OBJECTIVE

To study the implications of household tobacco and alcohol use on child health and women's welfare using a gender lens in Ethiopia, India, Indonesia, Jordan, Kenya, and Nigeria with varied geographical and cultural characteristics in the pattern of tobacco and alcohol use.

METHODS

We identified child health and women's welfare outcomes that may be impacted by tobacco and alcohol use, with a focus on the crowding-out effects on household resource allocation. For child health indicators, we focussed on engagement in preventative care, nutrition, and responses to acute illness. For women, we focused on access to resources for health-seeking and intimate partner violence (IPV). We used logistic regression to determine the association between household gender tobacco and/or alcohol use on child health and women's welfare, using data from six nationally-representative Demographic and Health Surveys, with each having a sample size of 5000-30,000 households and conducted after 2010.

RESULTS

Children in households where men and women use tobacco are significantly less likely to receive the full schedule of Diphtheria-Pertussis-Tetanus (DPT) vaccine in India, Indonesia, and Jordan (Odds ratio or OR; ORIndia = 0.67, p < 0.001; ORIndonesia = 0.55, p = 0.028; ORJordan = 0.45, p = 0.048), and all basic vaccinations as well as receive appropriate treatment for fever/diarrhoea in India and Indonesia (all basic vaccinations: ORIndia = 0.78, p < 0.001, ORIndonesia = 0.43, p = 0.009; treatment for fever/diarrhoea: ORIndia = 0.65, p < 0.001; ORIndonesia = 0.50, p = 0.038). In most countries, women are significantly more likely to experience IPV when their husband/partner uses tobacco and/or alcohol.

CONCLUSIONS

Across a diverse set of countries with varied cultural characteristics which affect the uptake and use of tobacco and alcohol, tobacco and alcohol use are associated with crowding-out of acute and preventative health-related behaviours and crowding-in of harmful behaviours. This has significant implications for tobacco and alcohol control programmes, and positions tobacco and alcohol control as central to human capital initiatives and in achieving health for all.

The effect of tobacco- and alcohol-control policies on household spending patterns in Kenya: An approach using matched difference in differences

This paper examines the effect of tobacco and alcohol control policies on tobacco and alcohol consumption patterns and the evolution of crowding-out effects on other household expenditure in Kenya. The current literature on crowding-out does not provide a defensible instrumental variable for a system of demand equations. This paper uses Matched Difference in Differences (MDID) as an alternative strategy and data from two nationally representative surveys in Kenya conducted ten years apart (2005/6 and 2015/16). We find that tobacco-control policies contributed to a decrease in the proportion of tobacco-consuming households between 2005 and 2015. Alcohol-control policies were only effective in reducing the proportion of alcohol-consuming households in the bottom quartile of the expenditure distribution. Overall, tobacco-consuming households spent less on education, communication, and some food items. Alcohol-consuming households also spent less on some food items, but expenditure on transportation was the only non-food item crowded out. Tobacco and alcohol control policies, when they result in reduced consumption of these products, can increase household expenditure on human capital development in the long run.

Socioeconomic inequality in tobacco expenditure in Iran: a cross-sectional analysis at national and subnational levels

BACKGROUND

Tobacco expenditure has adverse impacts on expenditure on basic needs and resource allocation of the households. Using data from a nationally representative survey, we measured socioeconomic inequality in tobacco expenditure as the share of household budget (TEHB) and explained its main determinants among Iranian households at the national and sub-national levels.

METHODS

This cross-sectional study used data from the Iranian Household Income and Expenditure Survey (IHIES), 2018. We included a total of 7649 households with tobacco expenditure more than zero in the analysis. Province-level data on the Human Development Index (HDI) was obtained from the Institute for Management Research at Radbound University. The concentration curve (CC) and the concentration index (C) were used to measure socioeconomic inequality in TEHB at national and sub-national levels. The C was decomposed to identify the factors explaining the observed socioeconomic inequality in TEHB.

RESULTS

At the national level, households with at least one smoker spent more than 5% of their budget for tobacco consumption in the last month. Households from the urban areas allocated less of their budgets on tobacco products compared to rural households (4.6% vs. 5.8%). Overall, TEHB was more concentrated among the poorer households (C = 0.1423, 95% CI: - 0.1552 to - 0.1301). In other words, the distribution of TEHB was pro-poor in Iran. Pro-poor inequality in TEHB was also found in urban (C = - 0.1707, 95% CI: - 0.1998 to - 0.1516) and rural (C = - 0.1314, 95% CI: - 0.1474 to - 0.1152) areas. We also found that pro-poor inequalities were higher in Iranian provinces with low HDI. The decomposition results indicate that wealth and education were the main factors contributing to the concentration of TEHB among the poorer households.

CONCLUSION

This study found that TEHB was disproportionality concentrated among poorer households in Iran. The extent of inequality in TEHB was higher in urban areas and less developed provinces. Designing and implementing tobacco control interventions to decrease the smoking prevalence and increase smoking cessation could protect worse-off households against the financial burden of tobacco spending.

Tobacco smoking patterns in Samoa in 2010: Implications for interventions

INTRODUCTION

Tobacco use in Samoa has been described over time by age, sex and education, but little work exists on other sociodemographic factors associated with tobacco use. We describe current smoking and daily tobacco use in adults from Samoa, with a focus on sex and age stratified analyses of the influence of occupation, education, census region, household asset ownership and alcohol use in order to help develop potential targeted interventions.

METHODS

In 2010, a nationwide survey of 3745 adults aged 25–65 years from 33 villages was completed in Samoa. Current smoking status, daily tobacco use, as well as current alcohol use, and a variety of sociodemographic factors were assessed by interview. Bivariate and multivariable models, and sex and age group stratified analyses, were performed to determine different patterns of correlates.

RESULTS

More than half of all men (51.3%) and 21.8% of women were current tobacco smokers. Men and women smoked on average 10.9 and 8.7 cigarettes/day, respectively. Twenty per cent of men consumed ≥20 cigarettes/day. In men, being married, a subsistence-farmer/laborer, an alcohol user, and having low household assets, were independently associated with being a tobacco smoker (all p<0.01). Among women, not completing secondary education, being 25–34 years, residing in urban Apia, and being an alcohol user, were independently associated with being a tobacco smoker (all p<0.01).

CONCLUSIONS

Tobacco use in Samoa remains high and correlates of smoking suggest that interventions for cessation need to be developed within the contexts of sex, age, education, and household socioeconomic status.

Expenditure on health care, tobacco, and alcohol: Evidence from household surveys in rural Puducherry

Background

Healthcare expenditures exacerbate poverty, with about 39 million people falling into poverty every year because of such expenditures. Tobacco and alcohol consumption in addition to harmful health impact have economic consequences at household level.

Aim

To evaluate healthcare, alcohol, and tobacco expenditures among households in rural Puducherry and their impact on household expenditure patterns.

Materials and Methods

A community-based cross-sectional analytical study was conducted in selected villages within 5 km of a medical college hospital in Puducherry from September 2016 to June 2017. Sociodemographic details and various household expenditures were obtained from 817 households with 3459 individuals. Data were analyzed using STATA (v14).

Results

Higher mean percentage of health expenditure was found among households with low socioeconomic status [17.7 (95% confidence interval (CI): 14-21.3)] and no health insurance schemes [13.4 (95% CI: 11.1-15.7)]. Households with low socioeconomic status [13.1 (95% CI: 7.5-18.7)] had higher tobacco-alcohol expenditure. Increased health expenditure among households was positively correlated with loan (r_s = 0.48). Increased alcohol-tobacco expenditure among households was negatively correlated with food (r_s= -0.52) and education (r_s= -0.70) expenditure.

Conclusion

Healthcare and alcohol-tobacco expenditure individually contributed to one-tenth of the household budget. Spending on healthcare, alcohol, and tobacco created significant negative influence on investment in human capital development.

The crowding-out effect of tobacco expenditure on household spending patterns in Bangladesh

BACKGROUND

Tobacco consumption constitutes a sizable portion of household consumption expenditure, which can lead to reduced expenditures on other basic commodities. This is known as the crowding-out effect. This study analyzes the crowding-out effect of tobacco consumption in Bangladesh, and the research findings have relevance for strengthening the tobacco control for improving health and well-being.

METHODS

We analyzed data from the Bangladesh Household Income and Expenditure Survey 2010 to examine the differences in consumption expenditure pattern between tobacco user and non-user households. We further categorize tobacco user households in three mutually exclusive groups of smoking-only, smokeless-only, and dual (both smoking and smokeless); and investigated the crowding-out effects for these subgroups. We compared the mean expenditure shares of different types of households, and then estimated the conditional Engel curves for various expenditure categories using Seemingly Unrelated Regression (SUR) method. Crowding-out was considered to have occurred if estimated coefficient of the tobacco use indicator was negative and statistically significant.

RESULTS

We find that tobacco user households on average allocated less in clothing, housing, education, energy, and transportation and communication compared to tobacco non-user households. The SUR estimates also confirmed crowding-out in these consumption categories. Mean expenditure share of food and medical expenditure of tobacco user households, however, are greater than those of tobacco non-user households. Albeit similar patterns observed for different tobacco user households, there were differences in magnitudes depending on the type of tobacco-use, rural-urban locations and economic status.

CONCLUSION

Policy measures that reduce tobacco use could reduce displacement of commodities by households with tobacco users, including those commodities that can contribute to human capital investments.

Relationship between smoking and health and education spending in Chile

Objective

To estimate the degree to which tobacco consumption is associated with spending on a set of goods and services in Chile, especially health and education, for the total population as well as for specific subgroups.

Methods

A seemingly unrelated regression equation system was used to estimate the statistical relationship between having tobacco expenditures and the budget share allocated to other items for the total population and for specific subgroups in Chile (eg, households within the bottom/top 33% by total expenditures). The use of household-level data allows for the control of a number of sociodemographic characteristics. The nationally representative 2012 Chilean Household Expenditure Survey was used for the analysis.

Results

Tobacco consumption is associated with lower budget shares allocated to healthcare, education and housing expenses, especially for poorer households. In the case of health, not consuming tobacco is related to higher health expenditures: up to 32% for the total population. Similarly, in the case of education, not consuming tobacco is statistically related to higher education expenditures: up to 16% for the total population. For all groups, tobacco consumption is also related to a significantly higher budget share allocated to alcoholic beverages.

Conclusions

The strong significant statistical relationship found between tobacco consumption and resources allocated to healthcare and education consumption may be indicative of the existence of a crowding out effect of tobacco. This effect, in turn, may increase the burden that the rest of society must bear for the increased healthcare that they require because of tobacco consumption.