Lifestyle and Income-related Inequality in Health in South Africa

BACKGROUND: Many low- and middle-income countries are experiencing an epidemiological transition from communicable to non-communicable diseases. This has negative consequences for their human capital development, and imposes a growing economic burden on their societies. While the prevalence of such diseases varies with socioeconomic status, the inequalities can be exacerbated by adopted lifestyles of individuals. Evidence suggests that lifestyle factors may explain the income-related inequality in self-reported health. Self-reported health is a subjective evaluation of people's general health status rather than an objective measure of lifestyle-related ill-health. METHOD: The objective of this paper is to expand the literature by examining the contribution of smoking and alcohol consumption to health inequalities, incorporating more objective measures of health, that are directly associated with these lifestyle practices. We used the National Income Dynamic Study panel data for South Africa. The corrected concentration index is used to measure inequalities in health outcomes. We use a decomposition technique to identify the contribution of smoking and alcohol use to inequalities in health. RESULTS: We find significant smoking-related and income-related inequalities in both self-reported and lifestyle-related ill-health. The results suggest that smoking and alcohol use contribute positively to income-related inequality in health. Smoking participation accounts for up to 7.35% of all measured inequality in health and 3.11% of the inequality in self-reported health. The estimates are generally higher for all measured inequality in health (up to 14.67%) when smoking duration is considered. Alcohol consumption accounts for 27.83% of all measured inequality in health and 3.63% of the inequality in self-reported health. CONCLUSION: This study provides evidence that inequalities in both self-reported and lifestyle-related ill-health are highly prevalent within smokers and the poor. These inequalities need to be explicitly addressed in future programme planning to reduce health inequalities in South Africa. We suggest that policies that can influence poor individuals to reduce tobacco consumption and harmful alcohol use will improve their health and reduce health inequalities

Analysing the Trend of Illicit Tobacco in the Philippines From 1998 to 2018

Tobacco taxation is the most effective measure to reduce cigarette consumption and consequently improve public health outcomes. It is also an important source of government revenue. The presence of an illicit tobacco market diminishes the public health and fiscal gains of cigarette levies by making cheaper non-taxed cigarettes available. To date, the research on the extent of illicit tobacco trade in the Philippines, despite its potential to inform policies for controlling the supply of illicit cigarettes, has been limited. This study provides an estimate of the size of the illicit tobacco market in the Philippines from 1998 to 2018. It employs gap analysis comparing an estimate of the survey-based adult cigarette consumption with legally sold cigarettes in the Philippines. The illicit trade estimates are contrasted with the evolution of tax changes. The results show that the illicit cigarette market share dropped by 42% from 2003 to 2008 and by an additional 79% from 2008 to 2013. In spite of the large tax increases by the Philippine government through the Sin Tax Law starting from 2013 until 2018, the illicit share in 2018 remains similar to its 1998 level of 16% of the total market. Hence, our study finds no evidence of a positive relationship between tobacco taxes and size of illicit cigarette market in the Philippines

Prices and Cigarette Demand: Evidence from Youth Tobacco Use in Developing Countries

This paper estimates the impact of cigarette prices on youth smoking in lower-income countries using data from the Global Youth Tobacco Survey (GYTS). Country-level heterogeneity is addressed with fixed effects and by directly controlling for confounding environmental factors such as local anti-smoking sentiment, cigarette advertising, anti-smoking media messages, and compliance with youth access restrictions. We find that cigarette price is an important determinant of both smoking participation and conditional demand. The estimated price elasticity of participation is -0.63. The likelihood of participation decreases with anti-smoking sentiment and increases with exposure to cigarette advertising. The estimated price elasticity of conditional cigarette demand is approximately -1.2. Neither anti-smoking sentiment, cigarette advertising, nor access restrictions have an impact on the intensity of smoking among current smokers, but exposure to anti-smoking media may reduce the number of cigarettes smoked.

Understanding Period Poverty: Socio-Economic Inequalities in Menstrual Hygiene Management in Eight Low- and Middle-Income Countries

Menstrual hygiene management and health is increasingly gaining policy importance in a bid to promote dignity, gender equality and reproductive health. Effective and adequate menstrual hygiene management requires women and girls to have access to their menstrual health materials and products of choice, but also extends into having private, clean and safe spaces for using these materials. The paper provides empirical evidence of the inequality in menstrual hygiene management in Kinshasa (DRC), Ethiopia, Ghana, Kenya, Rajasthan (India), Indonesia, Nigeria and Uganda using concentration indices and decomposition methods. There is consistent evidence of wealth-related inequality in the conditions of menstrual hygiene management spaces as well as access to sanitary pads across all countries. Wealth, education, the rural-urban divide and infrastructural limitations of the household are major contributors to these inequalities. While wealth is identified as one of the key drivers of unequal access to menstrual hygiene management, other socio-economic, environmental and household factors require urgent policy attention. This specifically includes the lack of safe MHM spaces which threaten the health and dignity of women and girls

Proactive Recruitment of Frontoparietal and Salience Networks for Voluntary Decisions

There is evidence that neural patterns are predictive of voluntary decisions, but findings come from paradigms that have typically required participants to make arbitrary choices decisions in highly abstract experimental tasks. It remains to be seen whether proactive neural activity reflects upcoming choices for individuals performing decisions in more complex, dynamic, scenarios. In this functional Magnetic Resonance Imaging (fMRI) study, we investigated proactive neural activity for voluntary decisions compared with instructed decisions in a virtual environment, which more closely mimicked a real-world decision. Using partial least squares (PLS) analysis, we found that the frontoparietal and salience networks were associated with voluntary choice selection from a time at which decisions were abstract and preceded external stimuli. Using multi-voxel pattern analysis (MVPA), we showed that participants' choices, which were decodable from motor and visual cortices, could be predicted with lower accuracy for voluntary decisions than for instructed decisions. This corresponded to eye-tracking data showing that participants made a greater number of fixations to alternative options during voluntary choices, which might have resulted in less stable choice representations. These findings suggest that voluntary decisions engage proactive choice selection, and that upcoming choices are encoded in neural representations even while individuals continue to consider their options in the environment

Estimating the Magnitude of Illicit Cigarette Trade in Bangladesh:Protocol for a Mixed-Methods Study

The illicit tobacco trade undermines the effectiveness of tobacco tax policies; increases the availability of cheap cigarettes, which, in turn, increases tobacco use and tobacco related deaths; and causes huge revenue losses to governments. There is limited evidence on the extent of illicit tobacco trade particularly cigarettes in Bangladesh. The paper presents the protocol for a mixed-methods study to estimate the extent of illicit cigarette trade in Bangladesh. The study will address three research questions: (a) What proportion of cigarettes sold as retail are illicit? (b) What are the common types of tax avoidance and tax evasion? (c) Can pack examination from the trash recycle market be considered as a new method to assess illicit trade in comparison to that from retailers and streets? Following an observational research method, data will be collected utilizing empty cigarette packs from three sources: (a) retailers; (b) streets; and (c) trash recycle market. In addition, a structured questionnaire will be used to collect information from retailers selling cigarettes. We will select post codes as Primary Sampling Unit (PSU) using a multi-stage random sampling technique. We will randomly select eight districts from eight divisions stratified by those with land border and non-land border; and within each district, we will randomly select ten postcodes, stratified by rural (five) and urban (five) PSU to ensure maximum geographical variation, leading to a total of eighty post codes from eight districts. The analysis will report the proportions of packs that do not comply with the study definition of illicit. Independent estimates of illicit tobacco are rare in low-and middle-income countries such as Bangladesh. Findings will inform efforts by revenue authorities and others to address the effects of illicit trade and counter tobacco industry claims

Assessment of the European Union's illicit trade agreements with the four major transnational tobacco companies

To address the illicit cigarette trade, the European Union (EU) has signed agreements with the four major Transnational Tobacco Companies (TTCs) that involve establishing extensive systems of cooperation. All agreements foresee two types of payments: annual payments (totalling US$ 1.9 billion over 20 years) and supplementary seizure payments, equivalent to 100% of the evaded taxes in the event of seizures of their products. While limited by the fundamental lack of transparency in this area, our analysis suggests that these agreements have served largely to secure the TTCs’ interests and are threatening progress in tobacco control. The seizure payments are paltry and a wholly inadequate deterrent to TTC involvement in illicit trade. Despite the agreements, growing evidence indicates the TTCs remain involved in the illicit trade or are at best failing to secure their supply chains as required by the agreements. The intention of the seizure-based payments to deter the tobacco industry from further involvement in the illicit cigarette trade has failed because the agreements contain too many loopholes that provide TTCs with both the incentive and opportunity to classify seized cigarettes as counterfeit. In addition, the shifting nature of cigarette smuggling from larger to smaller consignments often results in seizures that are too small to qualify for the payments. Consequently, the seizure payments represent a tiny fraction of the revenue lost from cigarette smuggling, between 2004 and 2012, 0.08% of the estimated losses due to illicit cigarette trade in the EU. Our evidence suggests the EU should end these agreements