Abstract
Previous studies on the associations between cigarette taxes and infant survival have all been in high-income countries and did not examine the relative benefits of different taxation levels and structures. We evaluated longitudinal associations of cigarette taxes with neonatal and infant mortality globally. We applied country-level panel regressions using 2008-2018 annual mortality and biennial WHO tobacco taxation data. Complete data was available for 159 countries. Outcomes were neonatal and infant mortality. We conducted analyses by type of taxes (i.e. specific cigarette taxes, ad valorem taxes, and other taxes, import duties and VAT) and the income group classification of countries. Covariates included scores for other WHO recommended tobacco control policies, socioeconomic, health-care, and air quality measures. Secondary analyses investigated the associations between cigarette tax and cigarette consumption. We found that a 10 percentage-point increase in total cigarette tax as a percentage of the retail price was associated with a 2.6% (95% Confidence Interval [CI]: 1.9% to 3.2%) decrease in neonatal mortality and a 1.9% (95% CI: 1.3% to 2.6%) decrease in infant mortality globally. Estimates were similar for both excise and ad valorem taxes. We estimated that 231,220 (95% CI: 152,658 to 307,655) infant deaths could have been averted in 2018 if all countries had total cigarette tax at least 75%. 99.2% of these averted deaths would have been in low- and middle-income countries (LMICs). The secondary analysis supported causal interpretation of results by finding that a 10 percentage-point increase in taxes was associated with a reduction of 94.6 (95% CI: 32.7 to 156.5) in annual cigarette consumption per capita. Although causal inference is precarious due to the quasi-experimental design, we used a robust analytical approach and focused on within-country changes. Limitations include an inability to include data on roll-your-own tobacco, other forms of tobacco use, and reliance on taxation data only for the cigarette brands most sold in each country. In line with limited existing evidence conducted in HICs, we found that raising taxes on tobacco was associated with a reduction in neonatal and infant mortality globally. Implementing recommended levels of taxation in LMICs should be a priority since this is where the lowest levels of taxation and the largest potential infant mortality benefits exist.
Highlights
Tobacco use has substantial adverse impacts on child health globally
The average neonatal and infant mortality rates were considerably higher in low- and middle-income countries (LMICs) (19.0 and 33.2, respectively) than in high-income countries (HICs) (3.7 and 5.6, respectively)
If all countries had instituted at least 75% total tax as recommended by World Health Organization (WHO), an estimated 231,220 infant deaths and 181,970 neonatal deaths, could have been averted in 2018 (Fig 2)
Summary
Tobacco use has substantial adverse impacts on child health globally. Exposure to second hand smoke (SHS) is estimated to kill 56,000 children under ten years of age each year around the globe primarily through exposure at home [1,2]. While existing studies show positive impacts of increased tobacco taxation on preterm birth, infant mortality and asthma exacerbations, this research has been conducted only in high-income countries (HICs) [11– 15]. These results may not be generalisable to low- and middle-income countries (LMICs) where high background air pollution, low awareness of tobacco-related harm, poor economic conditions, and high influence of the tobacco industry might suppress the positive effects of raising taxes [16–20]. The dearth of research globally, especially in LMICs with the largest burden of child mortality, may constrain further progress in tobacco control This is important as only 14% of the global population live in countries which achieve the WHO recommended level of taxation of at least 75% of the retail price [8]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
