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Original Investigation
November 2017

Association of Cigarette Price Differentials With Infant Mortality in 23 European Union Countries

Author Affiliations
  • 1Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, England
  • 2Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre–Sophia Children’s Hospital, Rotterdam, the Netherlands
  • 3Department of Obstetrics and Gynaecology, Erasmus University Medical Centre–Sophia Children’s Hospital, Rotterdam, the Netherlands
  • 4Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland
JAMA Pediatr. 2017;171(11):1100-1106. doi:10.1001/jamapediatrics.2017.2536
Key Points

Question  Are differentials in cigarette prices associated with increased infant mortality?

Findings  In this longitudinal, ecological study, increases in the median price of cigarettes were associated with reductions in infant mortality across Europe between 2004 and 2014. However, pricing differentials between median and minimum cigarette prices were associated with increases in infant mortality.

Meaning  Pricing differentials between cigarette products with widespread availability of budget cigarettes are likely to produce adverse child health outcomes; legislators should implement measures to eliminate budget cigarettes globally.


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 that maintain the availability of budget cigarettes.

Objective  To assess associations between median cigarette prices, cigarette price differentials, and infant mortality across the European Union.

Design, Setting, and Participants  A longitudinal, ecological study was conducted from January 1, 2004, to December 31, 2014, of infant populations in 23 countries (comprising 276 subnational regions) within the European Union.

Interventions  Median cigarette prices and the differential between these and minimum cigarette prices were obtained from Euromonitor International. Pricing differentials were calculated as the proportions (%) obtained by dividing the difference between median and minimum cigarette price by median price. Prices were adjusted for inflation.

Main Outcomes and Measures  Annual infant mortality rates. Associations were assessed using linear fixed-effect panel regression models adjusted for smoke-free policies, gross domestic product, unemployment rate, education, maternal age, and underlining temporal trends.

Results  Among the 53 704 641 live births during the study period, an increase of €1 (US $1.18) per pack in the median cigarette price was associated with a decline of 0.23 deaths per 1000 live births in the same year (95% CI, –0.37 to –0.09) and a decline of 0.16 deaths per 1000 live births the following year (95% CI, –0.30 to –0.03). An increase of 10% in the price differential between median-priced and minimum-priced cigarettes was associated with an increase of 0.07 deaths per 1000 live births (95% CI, 0.01-0.13) the following year. Cigarette price increases across 23 European countries between 2004 and 2014 were associated with 9208 (95% CI, 8601-9814) fewer infant deaths; 3195 (95% CI, 3017-3372) infant deaths could have been avoided had there been no cost differential between the median-priced and minimum-priced cigarettes during this period.

Conclusions and Relevance  Higher cigarette prices were associated with reduced infant mortality, while increased cigarette price differentials were associated with higher infant mortality in the European Union. Combined with other evidence, this research suggests that legislators should implement tobacco tax and price control measures that eliminate budget cigarettes.