Cigarette price differentials and infant mortality in 23 European Union countries

Importance: Raising the price of cigarettes by increasing taxation has been associated with improved perinatal and child health outcomes. Transnational tobacco companies have sought to undermine tobacco tax policy by adopting pricing strategies which maintain the availability of budget cigarettes. Objective : To assess associations between median cigarette prices, cigarette price differentials and infant mortality across Europe . Design : Longitudinal ecological study of regions within the European Union . Setting : 23 European countries; 2004 – 2014 (data from 276 sub - national regions ). Participants : Infant populations in relevant countries. Interventions : M edian cigarette prices and the differential between these and minimum cigarette prices were obtained from Euromonitor International . Pricing d ifferential s were calculated as the proportion s (% ) obtained by dividing minimum by median cigarette price. Prices were adjusted for inflation. Main outcome measure : Annual infant mortality rates. Associations were assessed using linear fixed - effect panel regression models adjusted for smoke - free policies; G ross D omestic P roduct ; unemployment rate; education; materna l age; and underlining temporal trends. Results : A €1 per pack increase in the median cigarette price was associated with a decline of - 0.23 deaths per 1,000 live births in the same year (95% Confidence Interval [CI]: - 0.37 to - 0.09) and - 0.16 per 1,000 l ive births the following year (95% CI: - 0.30 to - 0.03). An increase of 10% in the price differential between median and minimum priced cigarettes was associated with an increase of 0.07 deaths per 1,000 live births (95% CI: 0.01 to 0.13) the following year . C igarette price increases across 23 European countries between 2004 and 2014 were associated with 9 , 208 (95% CI: 8, 601 to 9, 814 ) fewer infant deaths; 3, 195 (95% CI: 3, 017 to 3, 372 ) infant deaths c ould have been avoided had there been no differential between median and the minimum priced cigarette s during this period . Conclusions and relevance: Higher cigarette prices were associated with reduced infant mortality, while increased cigarette price differentials were associated with hig her infant mortality in the European Union. Combined with other evidence this research suggests that legislators should implement tobacco tax and price control measures which eliminate budget cigarettes