We examined whether smokers who purchased low-taxed cigarettes from American Indian reservations had lower quit attempt and cessation rates than did smokers who purchased cigarettes from full-price outlets. Smokers who bought cigarettes from American Indian reservations were half as likely to make a quit attempt and had a nonsignificant trend toward lower cessation rates (20% vs 10%) compared with those who bought full-priced cigarettes. Interventions that reduce price differentials are suggested to maximize the public health benefit of cigarette excise taxes.
When cigarette prices increase, some smokers try to quit smoking or reduce the number of cigarettes they smoke,1–3 whereas others switch to cheaper brands or seek out less expensive outlets from which to purchase their cigarettes.4 Since November 1999, more than 30 states have increased cigarette excise taxes5; the New York State cigarette excise tax has increased by $0.94 to $1.50 per pack since March 2000.6
Cigarettes sold on American Indian reservations in New York State do not include state cigarette excise or sales taxes. A recent population-based study by Hyland et al.7 found that 67% of the smokers in the western New York State counties of Erie and Niagara reported that they usually purchased cigarettes on American Indian reservations, where the average price per pack is 40% of the price found in typical convenience stores. The entire population of Erie and Niagara counties resides within 30 miles of an American Indian reservation (Niagara County contains 2 American Indian reservations, and Erie County is within an hour’s drive of 4 American Indian reservations). Few studies have been conducted to determine whether the availability of less expensive cigarettes influences future indicators of smoking cessation. Data from the International Tobacco Control Policy Evaluation Survey found that quit rates were about 10% lower after 1 year among those who had purchased cigarettes from low-taxed or untaxed sources.8
We aimed to test the hypothesis that smokers who usually bought their cigarettes from American Indian reservations had lower rates of making quit attempts and lower cessation rates than did smokers who usually bought their cigarettes from full-price outlets.
A random-digit-dialed tobacco use telephone survey was administered to 1548 adults, including 908 smokers, in Erie and Niagara counties between October 2002 and May 2003 (60% response rate). One year later, 524 of these smokers completed a follow-up survey (retention rate = 58%). An analysis of the characteristics of responders to the follow-up survey found that they were more likely to be older, White residents of Erie County, compared with those who did not respond.
The usual source of cigarettes for baseline smokers was assessed with the following question: “From where are the cigarettes that you smoke usually purchased?” Respondents who answered “Indian reservation” were considered to be “usual” American Indian reservation purchasers. Cessation outcomes assessed were (1) making a quit attempt for a day or longer and (2) reporting currently smoking “not at all” at the follow-up survey.
Other control variables included gender, race, age, time from waking to first cigarette of the day, education, income, and county of residence.
The association between American Indian reservation purchasing and indicators of smoking cessation was examined with logistic regression models, while potential confounders were controlled. Results were weighted to the race, gender, and age distribution of the baseline smoker sample.
Respondents were more likely to be female (56%), White, non-Hispanic (84%), and between ages 25 and 44 (48%); to have 13 or more years of education (50%); and to earn between $15000 and $37500 annually. Most respondents reported at baseline that they smoked their first cigarette of the day within 30 minutes of waking (52%).
The percentage of the smokers who made quit attempts between the baseline and the follow-up interview was lower among those whose usual source of cigarettes was American Indian reservations at baseline (relative risk [RR] = 0.37; 95% confidence interval [CI] = 0.25, 0.54; P< .01). After we controlled for other factors related to smoking cessation, the relation was still statistically significant (RR = 0.46; 95% CI = 0.29, 0.74; P< .01).
Among those who reported usually purchasing their cigarettes from an American Indian reservation at baseline, 10% had quit smoking by the follow-up survey, compared with 20% of the smokers who reported usually purchasing their cigarettes from some other source at baseline (RR = 0.47; 95% CI = 0.28, 0.77; P< .01). After we controlled for other factors related to smoking cessation, this relation approached, but did not achieve, statistical significance (RR = 0.61; 95% CI = 0.33, 1.13; P= .12) (Table 1).
These data indicate that the accessibility to a source of low-taxed or untaxed cigarettes may reduce the likelihood that a smoker will make a quit attempt and quit smoking, thereby undermining the public health benefit of increased cigarette excise taxes.
Although the observed association for quitting in the current study was not statistically significant, the estimated effect size was about 40% and is much greater than previously reported results.8 This is not unexpected because the price differential from American Indian reservation sales compared with other sources is so great (60% cheaper).7 The lack of statistical significance may result from a relatively small number of quitters over the 1-year follow-up period. Furthermore, more research is needed to determine how generalizable these findings are to other locations.
In summary, most smokers in this sample reported making efforts to obtain low-taxed cigarettes from American Indian reservations, and this was associated with making fewer quit attempts. A borderline nonsignificant decrease in smoking cessation also was observed. The availability of low-taxed or untaxed cigarettes may inhibit motivation to attempt to quit smoking, thus undermining the public health benefit of higher cigarette excise taxes. Thus, interventions that reduce price differentials, such as a law prohibiting delivery of cigarettes to New York State addresses by mail, collecting excise taxes on cigarettes sold to American Indian retailers at the wholesale level, and raising the federal excise tax to reduce relative pricing differentials across borders, are suggested as a means to maximize the public health benefit of cigarette excise taxes.
Note. CI = confidence interval. The reference category is not usually buying cigarettes from an American Indian reservation. The adjusted P value for quitting smoking = .12. All other P values < .01. aRelative risks are adjusted for gender (male or female), race (White non-Hispanic vs all others), age (18–24 years, 25–44 years, 45–64 years, ≥65 years), time from waking to first cigarette of the day (≤5 minutes, 6–30 minutes, 31–59 minutes, ≥60 minutes), highest level of education (< 12 years, 12 years, 13–15 years, ≥16 years), income (< $15 000, $15 000–$37 500, $37 501–$60 000, or > $60 000 per year), and county of residence (Erie or Niagara County).
Relative Risk (95% CI) Outcome % Not Usually Buying % Usually Buying Crude Results Adjusted Resultsa Quit attempt 68.4 44.4 0.37 (0.25, 0.54) 0.46 (0.29, 0.74) Quit smoking 20.0 10.2 0.47 (0.28, 0.77) 0.61 (0.33, 1.13)
Note. CI = confidence interval. The reference category is not usually buying cigarettes from an American Indian reservation. The adjusted P value for quitting smoking = .12. All other P values < .01.
aRelative risks are adjusted for gender (male or female), race (White non-Hispanic vs all others), age (18–24 years, 25–44 years, 45–64 years, ≥65 years), time from waking to first cigarette of the day (≤5 minutes, 6–30 minutes, 31–59 minutes, ≥60 minutes), highest level of education (< 12 years, 12 years, 13–15 years, ≥16 years), income (< $15 000, $15 000–$37 500, $37 501–$60 000, or > $60 000 per year), and county of residence (Erie or Niagara County).
This research was funded by a grant from the New York State Department of Health and Erie-Niagara Tobacco-Free Coalition to Roswell Park Cancer Institute.
Human Participant Protection The institutional review board at Roswell Park Cancer Institute approved data collection procedures used in this survey.