Alcohol and tobacco use lead to enormous human and economic costs in the U.S. In the past few decades overall rates of smoking and drinking have declined [1, 2]. However, alcohol contributes to about 98,000 deaths annually , and smoking, 443,000 deaths . Annual direct and indirect alcohol-related costs approach $185 billion, while nearly $158 billion in health-related costs are ascribed to smoking [5, 6]. Raising prices through taxation on tobacco and alcohol products is a common strategy used internationally to raise revenues and reduce consumption, especially among youth [1, 2, 7–12]. Taxation policies are product specific and focus either on alcohol or tobacco. An emerging body of economic literature, however, documents the interactions between the price of tobacco and use of alcohol [13–18]. These “cross-price” influences reflect a change in the demand for a good (e.g. alcohol) in response to an increase in price of another good (e.g. cigarettes) . It is not known if increased prices on cigarettes are associated with binge or heavy alcohol drinking patterns across different age groups. To inform policymaking, it is important to know whether and how strategies to reduce cigarette use, such as cigarette taxation, influence drinking behaviors, and whether these effects differ across age groups.
Underlying mechanisms influencing use and co-use of alcohol and nicotine
Biological, genetic, behavioral, socio-demographic, and policy factors can provide insight into understanding the link between alcohol and tobacco use and co-use that may, in turn, influence how tobacco control policies influence drinking behavior. Studies suggest there are biological and shared genetic components in using and becoming dependent on alcohol and nicotine both separately and together [20–23]. Behavioral mechanisms also link alcohol and tobacco, such as level of impulsivity, self-medication for psychological issues such as anxiety and depression, and reinforcement effects that help to explain how smoking and drinking can be triggers for each other .
Socio-demographic factors such as age, gender, race/ethnicity, education, socio-economic status, marital status, and employment status are associated with differences in smoking and drinking [25, 26]. For example, younger people tend to have higher rates of smoking and binge drinking than those aged 65 and older [25, 26], men have higher rates of smoking and drinking than women [25, 26], Native Hawaiian/Pacific Islanders report the highest smoking and binge and heavy drinking rates compared to other racial/ethnic groups and Asian Americans report the lowest [25, 26]. Studies show that full-time college students have the highest rates of binge and heavy drinking and those with college degrees have lower rates of smoking than those with 9-11 years of education [25, 26]. Persons who are below the federal poverty level are more likely to smoke and less likely to drink than those who are above the federal poverty level [25, 27]. Those who are in a partnership, and specifically those who are married, are less likely to have problematic drinking patterns and are less likely to be smokers [28–30]. Persons who are employed or out of the workforce (e.g. homemakers, students, retired individuals) are less likely to smoke than those who are unemployed . The employed have higher rates of current drinking, but lower rates of problematic drinking than those who are unemployed .
Socio-economic and governmental practices and policies influence use. As an example, tobacco and alcohol companies use similar advertising and marketing practices which have been found to increase consumption of tobacco and alcohol [32, 33]. Governmental policies impacting the pricing, taxation, and sales of tobacco and alcohol products have been shown to influence consumption of both products, individually and together [34, 35]. Generally, higher prices reduce consumption of each product individually. Policies can also have impacts across products. For instance, tobacco control policies have been found to have effects on drinking behaviors. A study reported that smoking bans in bars are associated with higher traffic fatalities as drunk drivers travel further to bars allowing smoking .
Economics provides an understanding of further mechanisms influencing smoking and drinking. According to the theory of consumer demand, an increase in the price of a good (e.g. cigarettes) would be predicted to lower consumption of that good . However, demand theory also recognizes that relationships between the demands for products may exist, so that when prices increase on one product it can have different effects on the use of both products, depending on the relationship. For instance, if two products are close “substitutes,” a price increase in one (e.g. cigarettes) will make a consumer buy more of the substitute (e.g. alcohol), and the cross-price relationship will be positive . Alternatively, goods may be “complements,” in which case, when the price of cigarettes rises, the demand for both cigarettes and alcohol subsides, revealing a negative cross-price relationship .
In policy-making, cross-price relationships of goods may lead to intended and unintended consequences. For instance, increases in the price of cigarettes through taxation may decrease consumption of cigarettes (an intended consequence) and decrease harmful alcohol consumption if the goods are complements, arguably a positive unintended consequence. However, if the goods are substitutes and harmful drinking patterns amplify, then a negative unintended consequence might occur after cigarette prices increase. As policymakers may focus on the reduction of cigarette and alcohol consumption by youth and young adults as a reason for raising excise taxes, whether these taxes are associated with cigarette and alcohol use by young, in comparison with older persons, may be of interest to them.
While some literature examines the influence of cigarette prices on the prevalence and consumption of alcohol, there is no consensus among researchers on whether drinking increases or decreases as a result of cigarette prices [13, 14, 16–18, 38]. One study found that higher cigarette prices increase drinking among adults over the age of 18 . Others found a similar response among adults aged 51 and over , and among teens . In contrast, some studies found that increasing the price of cigarettes reduces drinking [14, 17, 39, 40]. Dee found that teens reduce drinking in response to increases in cigarette price, although in models with added controls, the relationship was no longer statistically significant . A study of those 14 and older in Australia reported reduced drinking in response to increased cigarette prices as did studies in the U.K. and Sweden using sales data [17, 39, 40].
Only one of these studies investigated the impact of increases in cigarette price on current and binge drinking . No studies have examined the influence of increases in cigarette price on different drinking patterns across various age groups. This is a notable gap since drinking and smoking rates vary dramatically by age. For example, the prevalence rates of binge drinking among adults aged 18-20 are 30-40%, are as high as 50% among adults aged 21-29, and are 23-30% among adults aged 30-49 . After age 50 binge drinking drops; 12-19% of adults aged 50-64 and 8% of adults over the age of 65 binge drink . While smoking prevalence rates are 20% for adults aged 18-64, they drop by half to 9.5% for persons over age 65 .
Given public health goals of preventing and reducing binge and heavy drinking, and the sharp differences in drinking patterns by age, this study aimed to address the significant gap in the literature on the impact of increased state cigarette price on alcohol drinking behaviors across age groups, with a particular focus on younger age groups. Since most of the U.S. research suggests that increases in cigarettes prices are associated with reductions in smoking and increases in drinking among the young, the primary hypothesis of this research was that increases in state cigarette prices would produce stronger reductions in current smoking, and stronger increases in current, binge, and heavy drinking among young adults (those under 30 years of age), than among those aged 30-64 and 65 and older.