Mongolia: Raising tobacco taxes is the most effective measure to reduce smoking

Researchers have evaluated the effectiveness of several tobacco control measures in Mongolia[1]All interventions (tax increases, smoking cessation aids, prevention campaigns) were based on the MPOWER package.[2] of the World Health Organization (WHO), with the exception of a school-based program. The latter was included with a view to preventing smoking among young people. In terms of health benefits and prevention of youth smoking, the largest gains were observed with tax increases on tobacco products.

The objective of this study is to inform policy makers about the cost-effectiveness of four population-based tobacco control interventions in Mongolia: tax increases, media campaigns, smoking cessation support, and school-based intervention programs.

The researchers used the Dynamic Population Health Modeling and Health Impact Assessment (DYNAMO-HIA) tool to project future smoking prevalence associated with these four tobacco control interventions and to simulate the resulting smoking-related morbidity over time. Using the most recent Mongolian national data, the costs and effects of these four interventions were compared to a status quo scenario, allowing for the calculation of costs per life-year gained and per disability-adjusted life-year (DALY). The implementation period for each intervention was set at three years.

As such, the study is exemplary of the use of existing modelling tools combined with local data to produce suitable data to support a country's policy decision.

The burden of smoking in Mongolia

Smoking prevalence has not changed over the past decade, with 27% of people aged 15 and over being smokers, and nearly one in two men smoking. Although average life expectancy has recently increased (70 years in 2018), men live almost nine years less than women: 67 years compared to 76 years, with this excess mortality among men being due in particular to this high prevalence of male smoking.

In 2013, the Mongolian government launched a national tobacco control strategy, which set targets for reducing smoking: by 2021, among adolescents aged 13 to 15, prevalence was to decrease from 6 % to 5 %, and among adults from 27 % to 22 %. This program envisaged increasing the share of excise taxes in the retail price of cigarettes from 25 % in 2017 to at least 60 % by 2021. Initially, the Excise Tax Law was amended to increase the tobacco excise tax by 10 % in 2018. Three annual increases of 5 % followed. This policy has led to excise taxes being levied at approximately 38 per cent of the total retail price. This proportion, even with VAT, remains below the recommendations of good practice in tobacco taxation, which provides for a minimum tax of 70 per cent of the retail price. In 2018, the WHO assessed Mongolia's tobacco control policy. Many measures were classified as "comprehensive policies," but the tax levels were deemed too low.

Raising tobacco taxes is the most effective course of action to reduce consumption and initiation

All interventions included in the assessment for this country reduced the prevalence of current smoking. The largest reduction was achieved through tobacco tax increases, which reduced prevalence by 5.1 percentage points. This was followed by media campaigns, which led to a 1.6 percentage point reduction, validated school-based intervention programs, which led to a 1.3 percentage point reduction, and finally, cessation support interventions, which reduced prevalence by 0.6 percentage points.

Among youth, a sharp increase in taxation would result in a lower quit rate and, even more so, a decrease in initiation. Therefore, the intervention's effect on youth is significantly greater than on adults. The authors point out that Mongolia has the potential to benefit significantly from tobacco tax increases, as nearly 60% of the population is under 35 years of age, and youth are more sensitive to price increases than adults. Furthermore, they note that reducing prevalence among men would be particularly significant given the current gap.

The authors of the analysis also recommend reducing price differences between different cigarette brands in Mongolia. Given this wide range of cigarette prices in Mongolia, the true level of price elasticity of demand is altered, with smokers switching to cheaper brands rather than quitting.

Particularly cost-effective measures which underline the relevance of the core MPower measures

The four types of intervention evaluated were shown to be highly cost-effective. Validated school programs that prevent initiation also reduce the associated costs of smoking and direct these funds toward treatment. The other interventions are also extremely relevant according to the WHO criterion, that of the cost-effectiveness ratio of the number of dollars spent per disability-adjusted life year (DALY) avoided. Thus, the number was 25 $ for media campaigns, 74 $ for tax policies and 1961 $ for cessation actions, the cost-effectiveness limit established being 4,295 $ / year.

In this perspective, the authors consider that it would be beneficial for Mongolia to extend all six interventions of the MPOWER program intended to rapidly and massively reduce tobacco consumption in a country. These measures, in addition to significant and continuous tax increases on tobacco products, are to warn about the dangers of tobacco via large graphic health warnings affixed to packaging, to protect people from passive smoking through the development of smoke-free places, and finally to adopt complete bans on all forms of advertising, promotion, sponsorship in favor of tobacco, including communication associated with so-called corporate social responsibility actions. Monitoring the effectiveness of these measures requires continuous surveillance of the tobacco epidemic and the evolution of prevalence thanks to regular studies on consumption.

Keywords: Mongolia, taxation, taxes, MPOWER, smoking, anti-smoking measures

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[1] Ariuntuya Tuvdendorj, PhD and others, Cost-Effectiveness of Four Tobacco Control Interventions in Mongolia, Nicotine & Tobacco Research, 2023;, ntad111, https://doi.org/10.1093/ntr/ntad111

[2] The MPOWER program is a set of six high-impact, cost-effective measures that help countries reduce tobacco demand: Monitoring tobacco use and prevention policies; Protecting the population from tobacco smoke; Helping people quit smoking; Prevention programs; Enforcing the ban on tobacco advertising, promotion, and sponsorship; and increasing tobacco taxes.

National Committee Against Smoking |