This chapter presents consumption trends of tobacco, both among adults and young individuals in countries in Latin America and the Caribbean (LAC). The chapter outlines the adverse effects of tobacco consumption, including the burden it places on public health, the substantial health expenditures it incurs, and the losses in productivity it entails. The chapter evaluates the current state of tobacco control policies within the region and discusses the impact of tobacco taxes in raising cigarette prices.
Tobacco Taxation in Latin America and the Caribbean
A Call for Tobacco Tax Reform
Abstract
Tobacco use remains widespread in LAC countries, particularly among males (Figure 1.1). Approximately 12% of people in LAC currently use tobacco, with males having a prevalence three-fold that of females. The highest tobacco use rates for males in the LAC region are observed in Chile, where nearly one in three males use tobacco (31%), followed by Argentina (29%). In contrast, the lowest rates among males are found in Panama (8%). The prevalence for females mirrors the pattern seen in males, with Chile and Argentina having the highest rates of tobacco use among females. However, countries with the lowest rates of tobacco use for females are Barbados, Guatemala, Honduras, Belize, El Salvador and Panama (prevalence rates below 2%).
Percentage of the population aged 15 years and over who currently use any tobacco product (smoked and/or smokeless tobacco) on a daily or non-daily basis, 2022
Note: Tobacco products include cigarettes, pipes, cigars, cigarillos, waterpipes (hookah, shisha), bidis, kretek, heated tobacco products, and all forms of smokeless (oral and nasal) tobacco. Tobacco products exclude e-cigarettes (which do not contain tobacco), e-cigars, e-hookahs, and e-pipes. The rates are age-standardized to the World Health Organisation (WHO) standard population. The LAC average was calculated as the weighted average of the countries included in the figure, according to the World Bank 2022 population data.
Source: WHO Global Health Observatory Data Repository (WHO, 2024[1]) using population data from (World Bank, 2022[2]).
Cigarettes are the most consumed tobacco product in LAC countries. In 2022, on average 86% of tobacco users in LAC smoked cigarettes (Figure 1.2). The rate is lower in the Dominican Republic where cigarette smoking represents 65% of tobacco use, which might be attributed to the popularity of other tobacco products such as cigars and pipes.
Percentage of the population that currently smoke cigarettes as % of all tobacco users, on a daily or non-daily basis, aged 15 years and older, 2022
Note: LAC countries with data on tobacco consumption in 2022. The numerator is current cigarette smoking prevalence; the denominator is current tobacco use prevalence, which includes cigarettes, pipes, cigars, cigarillos, waterpipes (hookah, shisha), bidis, kretek, heated tobacco products, and all forms of smokeless (oral and nasal) tobacco. Tobacco products exclude e-cigarettes (which do not contain tobacco), e-cigars, e-hookahs, and e-pipes. The rates are age-standardized to the WHO standard population. The LAC average was calculated as the average of the countries included in the figure.
Source: WHO Global Health Observatory Data Repository (WHO, 2024[1]).
In LAC countries, the average number of cigarettes smoked varies significantly (Figure 1.3). Retail data from 2022 indicates a four-fold difference between countries with the highest and lowest per-smoker cigarette consumption. On average, countries with a higher prevalence of tobacco use also have a higher number of cigarettes smoked per capita (noting that the data shows only legal sales per number of smokers while smokers may smoke both legal and illicit cigarettes). As such, while an average current smoker aged 15 or older in Bolivia smokes about 1 300 cigarettes per year, an average current smoker in Argentina – which is one of the countries with the highest prevalence of tobacco use – smokes 5 225 cigarettes per year (i.e. over 14 cigarettes per day, every day of the year).
Evidence from six LAC countries for which the Global Adult Tobacco Survey (GATS) is available shows that most current tobacco users aged 15 and older are daily consumers (Figure 1.4). In Brazil and Uruguay, 90% and 85%, respectively, of current smokers characterise themselves as daily smokers. Conversely, in Mexico and Panama, a different pattern emerges whereby there are slightly more occasional smokers than daily smokers (i.e. while a significant proportion of current smokers in these countries do smoke daily, a large proportion use tobacco more occasionally).
Cigarettes consumed annually per current smoker aged 15 years and older, 2022
Source: Euromonitor International Tobacco Industry edition, 2023 © All rights reserved (Euromonitor International, 2023[3]).
Percentage of daily smokers among all current tobacco users aged 15 and above
Note: Data was recorded from each country’s respective Global Adult Tobacco Survey (GATS) and therefore includes adults, aged 15 and older, tobacco users; except for Brazil, where those surveyed were over 18 years old.
Source: Global Adult Tobacco Survey Argentina 2012 (Government of Argentina, 2013[4]); Pesquisa Nacional de Saúde 2019 (Government of Brazil, 2021[5]); Global Adult Tobacco Survey Costa Rica 2022 (Government of Costa Rica, 2023[6]); Global Adult Tobacco Survey Mexico 2023 (Government of Mexico, 2023[7]); Global Adult Tobacco Survey Panama 2013 (Government of Panama, 2013[8]); Global Adult Tobacco Survey Uruguay 2017 (Government of Uruguay, 2017[9]).
The level of nicotine dependence varies by country. Nicotine dependence is typically measured with two indicators: the number of cigarettes consumed per day and the length of time elapsed between the moment the smoker awakens and the moment at which the first tobacco product is consumed. Of the six LAC countries that have available GATS data on the average number of cigarettes consumed per day for current daily smokers, Mexico had the lowest (average of 8.3 cigarettes per current daily smoker) and Panama and Uruguay had the highest (14.8 and 15.2 respectively) (Figure 1.5). Looking at the other measure of dependency, daily tobacco smokers in Brazil appear to be the most dependent (60% of daily smokers use tobacco within the first 30 minutes of waking), followed by Costa Rica and Panama. Daily smokers in Mexico and Argentina seem to depend less on tobacco as nearly 57% of them in each country, wait at least 60 minutes after waking to smoke.
Nicotine dependence in daily tobacco smokers aged 15 and older
Note: Data was recorded from each country’s respective GATS and therefore includes adults, aged 15 and older, tobacco users; except for Brazil, where those surveyed were over 18 years old. The 2019 report from Brazil and the 2022 report from Costa Rica did not capture the time to first smoke, so the data from the 2008 GATS Brazil and 2015 GATS Costa Rica was used for that metric.
Source: Global Adult Tobacco Survey Argentina 2012 (Government of Argentina, 2013[4]); Global Adult Tobacco Survey Brazil 2008 (Government of Brazil/ PAHO, 2010[10]); Pesquisa Nacional de Saúde 2019 (Government of Brazil, 2021[5]); Global Adult Tobacco Survey Costa Rica 2022 (Government of Costa Rica, 2023[6]); Global Adult Tobacco Survey Costa Rica 2015 (Government of Costa Rica, 2017[11]); Global Adult Tobacco Survey Mexico 2023 (Government of Mexico, 2023[7]); Global Adult Tobacco Survey Panama 2013 (Government of Panama, 2013[8]); Global Adult Tobacco Survey Uruguay 2017 (Government of Uruguay, 2017[9]).
Nicotine dependence does not exhibit a consistent pattern by sex across LAC countries. Surveys in Argentina and Panama show higher nicotine dependence among adult males compared to females, while in Brazil and Costa Rica, females exhibit higher dependence levels (Government of Argentina, 2013[4]; Government of Brazil/ PAHO, 2010[10]; Government of Costa Rica, 2017[11]; Government of Mexico, 2023[7]; Government of Panama, 2013[8]; Government of Uruguay, 2017[9]). The surveys for Uruguay and Mexico did not provide conclusive evidence of a consistent pattern of nicotine dependence based on sex.
There is a correlation between the age of smokers, socioeconomic family characteristics and nicotine dependence. Daily smokers aged 65 years and older are more likely to engage in smoking within 30 minutes of waking (48%), compared to the average smoking population (40% - figure based on the GATS from each country and averaged across countries). In addition, in general, surveys indicate that daily smokers with low household incomes and/or lower levels of education tend to exhibit higher levels of nicotine dependency. However, Mexico seems to be an exception because while there is still a slight distinction by educational attainment, the pattern is reversing, and tobacco use is lower among the lower income than the high income (U.S. National Cancer Institute/ WHO, 2016[12]). In Mexico, those with no formal education smoke an average of 8.3 cigarettes per day, with 43.5% of them smoking within the first 30 minutes of waking. In contrast, smokers with a university education smoke an average of 7.7 cigarettes per day, and only 21% smoking within the first 30 minutes of waking (Government of Mexico, 2023[7]). Findings corroborate a 2016 review documenting an inverse relationship between income and tobacco use in LAC countries (Bardach et al., 2016[13]).
The demand for cigarettes in LAC countries is relatively inelastic. This means that the quantity of cigarettes demanded does not change significantly with the change in price. In most LAC countries, the own-price elasticity for cigarettes is likely below -0.5, with a short-term elasticity of -0.31 and a long-term elasticity of -0.43 (Guindon, Paraje and Chaloupka, 2018[14]).1 A price elasticity of -0.31 means that a 10% increase in the price of cigarettes would lead to a decrease of 3.1% in the quantity demanded.
There have been significant decreases in tobacco use over the past two decades in the LAC region. In 2005, about 20% of individuals over the age of 15 used tobacco, but this rate decreased to 12% by 2022 (Figure 1.6). During this period, the rate of reduction in tobacco use among males was 34%, while among females, it was 45%.
Tobacco use prevalence trends by sex among people aged 15 and older in LAC countries
Note: The average prevalence for tobacco use per year includes Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Lucia and Uruguay. Tobacco products include cigarettes, pipes, cigars, cigarillos, waterpipes (hookah, shisha), bidis, kretek, heated tobacco products, and all forms of smokeless (oral and nasal) tobacco. Tobacco products exclude e-cigarettes (which do not contain tobacco), e-cigars, e-hookahs, and e-pipes. The rates are age-standardized to the WHO standard population.
Source: Data for prevalence was extracted from the WHO Global Health Observatory Data Repository (WHO, 2024[1]).
However national surveys suggest not all LAC countries are experiencing meaningful decreases in tobacco use. Despite macro-level declines in tobacco use over the last 17 years, significant strides remain to be achieved within each country, especially due to the recent stalling in the decrease in tobacco use from 2020 to 2022, as shown in the figure above. An example of this phenomenon includes Chile, where the overall prevalence of tobacco use declined from 35.2% in 2018 to 32.5% in 2020. However, at the same time, the prevalence of tobacco use for daily users and the prevalence of individuals who have ever used tobacco did not decrease (Government of Chile, 2021[15]). Further, there was a statistically significant increase in smoking intensity – measured as the number of smoking days per month (from 21 days in 2018 to 22 days in 2020) (Government of Chile, 2021[15]).
The COVID-19 pandemic has had a negative impact on smoking prevalence in various countries. The pandemic contributed to elevated levels of stress, disruption and social isolation, potentially contributing to a rise in smoking prevalence, or a lack of decline (Sarich et al., 2022[16]). This has contributed not only to a slower decline in prevalence rates, and some countries have experienced an increase in tobacco use prevalence among certain strata of population (i.e. high-income populations in Mexico).
There exists a significant variation (by nearly 20 percentage points) in the prevalence of young people who are tobacco users across LAC countries (Figure 1.7). In half of the LAC countries, tobacco use prevalence among young people is higher than amongst the adult population. At the same time, the prevalence of tobacco use among young people in most LAC countries follows the same trend of adults, as LAC countries with low rates of adult tobacco use also tend to experience lower levels among young people. For instance, like the adult population in the LAC region, numerous countries in the LAC report a tobacco use prevalence below 15% for young people aged 13 to 15. The countries with the lowest proportion of young people who use tobacco in LAC include El Salvador, Peru, and Costa Rica. Conversely, some countries exhibit a high prevalence of tobacco use among young people, akin to the adult population. The LAC countries with the highest proportion of young people using tobacco are found in Argentina and Chile, where 20% and 25%, respectively of people aged 13 to 15 are tobacco users.
The average age of initiation of smoking does not seem to be correlated with the prevalence of tobacco use amongst young people (aged 13 to 15) in LAC countries. At the same time, while the age of initiation for daily smokers hovers around 16 to 18, the risk of starting daily smoking begins in pre-adolescence. A 2023 report of three Latin American countries, including Argentina, Brazil and Mexico, shows a positive likelihood of initiation around aged 12 or 13, with a peak at age 17 (Franco-Churruarin and González-Rozada, 2023[17]). The average age of daily smoking initiation is 18.8 in Mexico, 17.0 in Argentina, 17.0 in Brazil, 16.9 in Panama, 16.3 in Uruguay and 16.1 in Costa Rica (Franco-Churruarin and González-Rozada, 2023[17]; Government of Costa Rica, 2017[11]; Government of Mexico, 2023[7]; Government of Panama, 2013[8]; Government of Uruguay, 2017[9]).
Prevalence of tobacco use amongst young people (13-15 years old) versus adult population (aged 15 and older), 2022
Note: Tobacco products include cigarettes, pipes, cigars, cigarillos, waterpipes (hookah, shisha), bidis, kretek, heated tobacco products, and all forms of smokeless (oral and nasal) tobacco. Tobacco products exclude e-cigarettes (which do not contain tobacco), e-cigars, e-hookahs, and e-pipes. Data for adults are age-standardized to the WHO standard population. The LAC average was calculated as the average of the countries included in the figure.
Source: WHO Global Health Observatory Data Repository (WHO, 2024[1]). Countries with an asterisk did not have data on prevalence for young people from the Global Health Observatory, so were extracted from Health at a Glance: Latin America and the Caribbean (OECD/The World Bank, 2023[18]).
Electronic cigarette usage stands out as a prevalent form of nicotine product among LAC youth (Figure 1.8). On average, 8% of individuals aged 13 to 15 currently consume nicotine in the form of electronic cigarette (e-cigarette2) in LAC. Trinidad and Tobago have the highest prevalence of e-cigarette use during the past 30 days (nearly 18% of youth use e-cigarettes), followed by Paraguay (12%) (Figure 1.8). Traditional cigarettes are the second-most common method of nicotine consumption amongst young people, with 7.7% of youth aged 13 to 15 opting for this form of nicotine. Argentina, Mexico, and Haiti have the highest prevalence of cigarette smoking among young people aged 13-15, ranging from 14% to 18%. Conversely, Antigua and Barbuda, the Dominican Republic, and Paraguay have the lowest prevalence of cigarette smoking among young people, all under 3%. Smokeless tobacco has a smaller prevalence compared to cigarette smoking and e-cigarettes, with Venezuela and Dominica having the highest prevalence of smokeless tobacco for children, at around 8% each (Figure 1.8).
Prevalence of current tobacco use (in the past 30 days) among young people aged 13-15, by nicotine product
Note: All data came from the most updated Global Youth Tobacco Survey for young people aged 13-15. Data ranges from 2009 until 2019.
Source: Data for prevalence was extracted from the WHO Global Health Observatory Data Repository (WHO, 2024[1]).
Tobacco consumption is the leading cause of preventable death and disability and a major driver of health costs and lost productivity. Users of tobacco are at risk of a variety of poor health outcomes over their life course, including non-communicable diseases. As there is no proven safe level of tobacco consumption (United States government, 2017[19]), tobacco smoking has adverse effects on both the individual- and population-level. Different types of costs are attributable to tobacco smoking, specifically:
Health burden including cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and cancers;
Health expenditure caused by smoking-related diseases or second-hand smoke. In addition, addressing nicotine addiction is also cause of additional treatment costs;
Productivity losses generated by reduced workforce participation due to increased ill health and mortality caused by tobacco-related diseases, both for the caregiver and individual themself.
1.4.1. The health burden of tobacco use
Every year, over 350 000 individuals die from tobacco use and second-hand smoke in the LAC region (Table 1.1). Estimates suggest that second-hand smoke alone is responsible for over 52 000 deaths every year, equating to approximately 3% of adult deaths in the LAC region. While the number of deaths attributed to tobacco use and second-hand smoke varies greatly across the region due to differing population sizes in each country, some countries have higher proportions of deaths from second-hand smoke than others. For example, Guatemala, Nicaragua, and Chile all have rates above 20%, meaning that 20% of tobacco-related deaths in these countries are attributed to second-hand smoke. In contrast, countries with the smallest fraction of deaths from second-hand smoke include Barbados, Uruguay, and the Dominican Republic, each at around 11%. Estimates also suggest that nearly 70 million smokers are at risk of tobacco-related death and disease in the region (Astudillo, Cruces and Puig, 2022[20]).
2021
Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (Institute for Health Metrics and Evaluation, 2024[21]).
Tobacco consumption poses a significant health challenge in the LAC region. The ten most common causes of death due to tobacco use include ischemic heart disease, COPD, tracheal, bronchus, and lung cancer, stroke, lower respiratory infections, diabetes mellitus, larynx cancer, aortic aneurysm, oesophageal cancer and stomach cancer (Figure 1.9). This group of conditions contribute to 88% of the tobacco-associated deaths in the region. In the LAC region, nearly 70 000 tobacco users die each year from ischemic heart disease (26% of tobacco-related deaths per year), followed by COPD (16%) and tracheal, bronchus and lung cancers (14%).
Ten most prevalent tobacco-related causes of death in LAC countries, 2021
Note: The left-hand side y-axis illustrates the number of deaths per year. The right-hand side y-axis illustrates the percentage of the condition as a fraction of all-cause mortality in 2021, encompassing all ages and both sexes in aggregated LAC counties.
Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (Institute for Health Metrics and Evaluation, 2024[21]).
While ischemic heart disease is the most common cause of death for tobacco users, tobacco smoking is the primary contributing risk factor for lung cancer and a variety of other respiratory illnesses, such as COPD. In LAC countries, over 40% of the cases of respiratory cancers are attributable to tobacco use (Figure 1.10), though this figure varies between 21% in Haiti to 62% in Uruguay and Paraguay. This pattern mirrors what is observed in the prevalence of tobacco use, seen in Figure 1.1, whereby the countries with the lowest prevalence of tobacco use also have the lowest rates of respiratory cancers and vice versa.
Percent of tracheal, bronchus, and lung cancers attributable to tobacco use, 2021
Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (Institute for Health Metrics and Evaluation, 2024[21]).
1.4.2. The impact of tobacco-related diseases on health expenditure
Health expenditure primarily results from the treatment of the conditions associated with tobacco use. The health expenditure associated with tobacco use encompasses expenses for hospitalisation, outpatient care, medications and therapies for individuals affected by tobacco-related diseases. Moreover, addressing nicotine addiction incurs additional treatment costs, encompassing counselling services, nicotine replacement therapy, and medications like nicotine patches or prescription drugs designed to assist individuals in quitting smoking. Further, apart from the health expenses incurred by smokers themselves, there are also costs associated with providing health to individuals exposed to second-hand smoke, particularly children and non-smoking adults. There are also environmental costs that are associated with tobacco use – ranging from the impact of tobacco production and manufacturing to the management of waste throughout and after production. These means that many estimates do not account for a range of additional costs, leading to significant underestimation of tobacco costs, particularly in countries with extensive tobacco cultivation.
Annual smoking-attributable medical costs in LAC countries vary significantly from one country to another (Table 1.2). Uruguay, Paraguay, Chile, and Bolivia stand out with the highest smoking-attributable medical costs as a proportion of gross domestic product (GDP), amounting to 1.5% for Uruguay and 0.8% for the others (Pichon-Riviere et al., 2020[22]). Conversely, Honduras demonstrates the lowest per capita cost of smoking, with annual smoking-attributable medical costs equivalent to 0.3% of annual GDP, representing 3.5% of total health expenditure. This discrepancy correlates with variations in smoking intensity per capita, where Uruguay, Paraguay, and Chile have relatively high smoking intensity and/or tobacco use prevalence rates, while Honduras ranks lower (see Figure 1.3). Note that the low ranking of Honduras could be an artifact of the capacity of the health infrastructure and, therefore, may not accurately represent the true costs needed to address smoking-attributable medical expenses. Despite the catastrophic economic and public health impact of tobacco use in the LAC region, amounting to a predicted annual USD 27 billion, only about a third of the cost is covered through tobacco taxes, on average (see also Box 1.1).
Percent of total health expenditure and GDP represented by smoking-attributable medical costs, proportion recovered through tobacco taxes, per capita cost of smoking-attributable medical costs in 2015
Note: All costs are in 2015 USD million. Information for this table was acquired from Table 1 and Table 3 of the source cited below.
Source: Adapted from (Pichon-Riviere et al., 2020[22]).
Two studies have computed the tax revenue and costs associated with tobacco use. They conclude that existing tobacco tax revenues account for only a fraction of the economic costs attributed to tobacco use.
A 2023 study concluded that current tobacco taxes cover 15% of the economic losses in the LAC region (using data from eight selected countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico and Peru). This study estimated that while all eight countries were far from recovering the costs generated by tobacco consumption through tobacco taxation, recovery shares ranged from as low as 4.4% in Peru to 29.2% in Chile. Costs accounted for in this study included productivity losses due to premature death and disability, caregiver’s costs, and medical costs (Pichon-Riviere et al., 2023[23]).
Another study concluded that tax revenue generated from cigarette sales accounted for 36% of the estimated health costs attributed to smoking in 12 LAC countries in 2015 (Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Mexico, Paraguay, Peru and Uruguay) (Table 1.2). Expenses covered both medical costs and reductions in quality of life linked to prevalent tobacco-related diseases (Pichon-Riviere et al., 2020[22]).
As such, increasing cigarette prices through taxation would yield significant health and economic benefits. For example, it was calculated that implementing a 50% increase in cigarette prices through taxation across 12 LAC countries would potentially prevent over 300 000 deaths, reduce the occurrence of 1.3 million disease events, and gain 9 million healthy life-years, and lead to savings of USD 27 billion in health expenses over the next decade (Pichon-Riviere et al., 2020[22]). The cumulative economic value of such an initiative would amount to USD 44 billion in the LAC region (Pichon-Riviere et al., 2023[23]).
1.4.3. Productivity losses associated with tobacco use
The lost human capital that results from tobacco-attributable morbidity and mortality are as large as the health costs at a societal level (WHO, 2022[24]). This includes the broader social and economic consequences of smoking, such as reduced productivity due to absenteeism at work with negative economic consequences for both the employer and the employee. Estimates suggest that these other costs account for more than 50% of the total economic burden associated with tobacco use (Pichon-Riviere et al., 2023[23]) (Figure 1.11). A study of eight LAC countries that account for health and economic costs concluded that the economic losses associated with tobacco use equate to USD 50 billion (Pichon-Riviere et al., 2023[23]). The size of this economic loss attributable to tobacco represents 1.4% of the combined GDP of Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, and Peru (countries accounting for 80% of the Latin American population).
Annual economic cost attributable to tobacco use by source, as a percentage of total cost, 2020
Source: Data adapted from (Pichon-Riviere et al., 2023[23]).
Many factors have contributed to the decrease in tobacco use in the LAC region. Among these factors are widespread anti-smoking campaigns, public health initiatives, and smoking bans which have improved awareness of the health risks associated with tobacco use, increased the price, and decreased the accessibility of tobacco products (Rodriguez-Iglesias and Chaloupka, 2018[25]; Sandoval et al., 2022[26]). Some countries have also combined interventions in comprehensive tobacco control programmes which included policies such as graphic warnings on tobacco packaging, smoking bans in public spaces, and increased tobacco taxes (WHO, 2019[27]).
Tax and non-tax measures are complementary and interact to determine overall success of government tobacco interventions. While taxes are the most effective method to reduce tobacco use, non-tax measures are also necessary for effective and long-term success in tobacco use cessation (Hutchinson et al., 2022[28]; Paraje, Muñoz and Pruzzo, 2023[29]). As such, although the rest of this report focuses primarily on tobacco policy in the form of taxation, it does not mean that non-tax reforms are not needed.
The WHO Framework Convention on Tobacco Control (WHO FCTC) establishes guidelines aimed at addressing the tobacco epidemic and implementing tobacco control measures. Assessing the degree of WHO FCTC implementation can serve as a benchmark for a country's performance in this regard. The MPOWER policy package offers a means to benchmark countries based on their adherence to these guidelines (Box 1.2) (WHO, 2020[30]).
The WHO FCTC was developed in 2005 in response to the globalization of the tobacco epidemic. It aims to tackle some of the causes of that epidemic, including complex factors with cross-border effects, such as trade liberalization and direct foreign investment, tobacco advertising, promotion and sponsorship beyond national borders, and illicit trade in tobacco products. It is the first international public health treaty negotiated under WHO auspices and contains guidelines and requirements for the implementation of the most cost-effective tobacco control measures available necessary for reducing the tobacco epidemic.
Some of the key interventions that Parties to the WHO FCTC are required to implement include the importance of tobacco taxes and price measures (Article 6); protection from second-hand smoke in all indoor workplaces and public places and public transportation (Article 8); large graphic health warnings on the packaging of tobacco products (Article 11); and a comprehensive ban on tobacco advertising, sponsorship, and promotion (Article 13).
These measures can be considered the starting point for the comprehensive implementation of the Convention. The treaty also addresses several other issues, including the disclosure and regulation of ingredients in tobacco products, forbidding the sale of tobacco products by or to minors, treatment for tobacco addiction, research, and exchange of information among countries and promoting public awareness.
While the WHO’s FCTC guidelines provide the foundation for countries to implement and manage tobacco control, the MPOWER policy package was developed in 2007 to provide the tools necessary for action on tobacco control. The MPOWER measures are used to assist in the country-level implementation of effective interventions to reduce the demand for tobacco. The acronym represents the following:
Monitoring tobacco use and prevention policies.
Protecting people from tobacco smoke.
Offer help to quit tobacco use.
Warn about the dangers of tobacco.
Enforce bans on tobacco advertising, promotion, and sponsorship.
Raise taxes on tobacco.
As of 2023, 183 parties have ratified the FCTC treaty. All LAC countries except Argentina, Cuba, the Dominican Republic and Haiti are Parties of the WHO FCTC. The implementation of tobacco control measures has progressed in recent years, especially in low- and middle-income countries where the heaviest burden of smoking is concentrated. Currently, over half of the world’s population benefits from large graphic health warnings on tobacco packages, and one-third have access to cessation services provided at best-practice levels.
Source: WHO 2021 global progress report on implementation of the WHO Framework Convention on Tobacco Control (WHO, 2022[24]); WHO report on the global tobacco epidemic (WHO, 2021[31]); OECD Health at Glance 2021 (OECD, 2021[32]).
The MPOWER policy package facilitates the assessment of effective tobacco control policies across countries. All the columns of Table 1.3 report the level of implementation in the country for each of the six policies identified in the MPOWER strategy. Each MPOWER policy area is scored per criteria outlined in Annex Table 1.A.1 where the colour scheme signifies performance levels, with the darkest blue denoting the implementation of a best practice, followed by lighter blues, corresponding to a lower performance category in the respective policy area.
Status of the WHO FCTC in LAC countries and a summary of applying the MPOWER policy package, 2022 data release
Notes: For the definitions and the colours of the classification of the interventions, see Annex 1.A to this chapter.
Data for each indicator was assessed by the WHO on 31 December 2022. Exceptions to this cutoff date were tobacco product prices and taxes (cut-off date 31 July 2022) and anti-tobacco mass media campaigns (cut-off date 30 June 2022).
* Numbers represent levels of compliance (out of 10 possible, where 0 represents the lowest and 10 represents the highest score) = 8-10 represent complete compliance; 3-7 represent moderate compliance; 0-2 represent minimal compliance.
✩ Plain packaging is mandated.
... Data not reported/not available.
– Data not required/not applicable.
The measure R applies to cigarettes only while the other measures apply to all tobacco products.
Affordability of cigarettes: Yes = Cigarettes less affordable – per capita GDP needed to buy 2 000 cigarettes of the most sold brand increased on average between 2012 and 2022; No = Cigarettes more affordable – per capita GDP needed to buy 2 000 cigarettes of the most sold brand declined on average between 2012 and 2022. ↔ = No trend changes in affordability of cigarettes between 2012 and 2022.
Source: Adapted from WHO report on the global tobacco epidemic (WHO, 2023[33]).
Countries in LAC have made substantial progress in implementing the MPOWER policy package. Of the 33 countries in the LAC region, 25 countries have achieved the highest level of application of at least one measure of the MPOWER policy package (Table 1.3). Brazil outperforms the other LAC countries, with the highest application across all MPOWER measures. Uruguay follows with five MPOWER measures, then Chile, Costa Rica, Mexico, and Panama follow, each attaining the highest application on four of the MPOWER policy measures. Conversely, the countries with the lowest achievement across the MPOWER policy package are the Bahamas, Belize, Dominica, the Dominican Republic, Grenada, Haiti, Saint Kitts and Nevis, and Saint Vincent and the Grenadines.
Only seven LAC countries have fully implemented tobacco consumption monitoring policies (measure M). This means that only these seven countries possess surveillance systems that provide up-to-date, regular, and comprehensive data regarding tobacco consumption among both adult and youth populations. Monitoring tobacco use has been hampered by the COVID-19 pandemic as data collection efforts were hindered between the years of 2020 to 2022, as was the release of results for surveys completed before and during the pandemic (WHO, 2023[33]). This clarifies the decrease in the number of countries achieving higher MPOWER implementation levels in the 2022 data compared to the 2020 data. While only five countries, including Barbados, Belize, Dominica, Haiti, and Saint Kitts and Nevis, lacked recent representative data on tobacco use prevalence among adults and youth in the 2020 report, the 2022 survey reveals that 10 countries lacked such data. These countries are Barbados, Belize, Dominica, the Dominican Republic, Grenada, Guatemala, Guyana, Honduras, Saint Kitts and Nevis, and Suriname (Table 1.3).
Most countries in the LAC region have successfully established smoke-free environments (measure P). Compared to other WHO regions, the LAC region has implemented measure P at the highest level of application (as of 31 December 2022) (WHO, 2023[33]). Countries with the highest standards in this category have completely smoke-free public places, indoor workplaces, and public transportation. There are, however, seven countries (Bahamas, Belize, Dominica, Grenada, Haiti, Saint Kitts and Nevis, and Saint Vincent and the Grenadines) that do not have bans to ensure that at least two types of public spaces and workplaces are completely smoke-free. The most common public spaces for which no smoking ban is enforced among these seven countries include health facilities, educational facilities, and universities (WHO, 2023[33]).
Only about 10% of LAC countries reach best practice in cessation services (measure O). Only four countries (Brazil, Costa Rica, Jamaica, and Mexico) have a national quit line, and offer nicotine replacement treatment and other cessation services cost-covered. The majority of countries fall into the two middle categories of implementation, meaning that nicotine replacement treatment and/or some cessation services are available though neither are cost-covered or that nicotine replacement treatment and/or some cessation services are available and at least one of them is cost-covered (WHO, 2023[33]). Four countries provide no cessation services (Antigua and Barbuda, Dominica, Grenada, and Haiti).
The LAC region has succeeded in the packaging and labelling of tobacco products and the implementation of anti-tobacco national mass media campaigns (measure W with two subcategories for health warnings and mass media). Nineteen LAC countries that achieved best practice in this measure have warnings that cover an average of at least 50% of the front and the back of the packaging with all the appropriate characteristics. Conversely, nine countries (Bahamas, Belize, Dominica, the Dominican Republic, Grenada, Guatemala, Haiti, Saint Kitts and Nevis, Saint Vincent and the Grenadines) fall into the lowest implementation category for this measure. This implies that these countries lack mandatory tobacco warnings or have small warnings (averaging less than 30% on the front and back). Additionally, they have not executed a national anti-tobacco campaign lasting at least three weeks between July 2020 and June 2022.
Less than one-third of LAC countries have achieved the highest level of implementation for comprehensive monitoring and enforcement of bans on tobacco advertising, promotion, and sponsorship (measure E). While nine countries in the LAC region implement measures relating to tobacco advertising, promotion, and sponsorship at the highest level of application, 16 countries have a complete absence of a ban or enforce a ban that does not at least cover national television, radio, and print media.
Only four LAC countries have achieved the highest level of implementation for the share of indirect taxes in the retail price of tobacco products (measure R). To reach best practice, the indirect tax share that consists of tobacco excise taxes but also other indirect taxes such as the value added tax (VAT), should reach at least 75% of the retail price. Only four countries (Argentina, Brazil, Chile, and Nicaragua) have achieved best practice in this component (Table 1.3 and Figure 1.12). More than half of the countries (20) receive a low R score as the tax share stays below 50% of the retail price. Of these twenty countries, six countries including Antigua and Barbuda, Cuba, Guyana, Paraguay, Saint Kitts and Nevis, Saint Vincent and the Grenadines, have tax shares below 25% of the retail price, with Cuba having the lowest tax share at 10% (Table 1.3 and Figure 1.12).
The MPOWER R underlying assumption is that a high tax share reflects a high level of taxes and, therefore, a high tax-inclusive price of cigarettes. As such, this indicator recognises that increased prices of tobacco as a result of high taxes is one of the most effective tools to reduce tobacco use (Ngo et al., 2022[34]; Sandoval et al., 2022[35]). High prices will create an incentive for smokers to quit or reduce smoking and deter potential smokers from starting. Additionally, higher prices make cigarettes less affordable and discourage youth from starting to smoke.
With a few exceptions, the indirect tax share in retail prices remains relatively low in countries in LAC, at least when compared to the WHO 75% tax share target. In 2022, the tobacco tax share was 46.7% of the retail price of the most sold brand of cigarettes on average across countries in LAC (Figure 1.12). While the weighted average price of cigarettes is usually preferred over the most sold brand of cigarettes to capture market shares, this data is not accessible for all LAC countries. Hence, the rest of the report uses most sold brands of cigarettes prices.
Surprisingly, LAC countries that meet the R target have lower cigarette prices than countries with more moderate tax shares (Figure 1.13). Countries with a tobacco tax share above 75% have, on average, lower cigarette prices (USD purchasing power parity PPP 5.9) than countries with tobacco tax shares between 25% and 75% (USD PPP 7.4 and 8.2, respectively). For instance, Brazil is the country with the second highest tobacco tax share (80%) (Figure 1.12) in the LAC region but is also the country with the second lowest cigarette retail prices (USD PPP 2.1) (Figure 1.13) with cigarettes remaining very affordable (Figure 1.14). Hence, there is no guarantee that cigarette will be expensive (i.e. with high prices) in countries that meet the 75% tax share target. This is why the cigarette tax scorecard was developed to consider jointly cigarettes prices, affordability, tax share and excise tax structure (Drope et al., 2024[36]).
On the other hand, LAC countries that are the worst R performers have the lowest cigarette prices in the region (Figure 1.13). LAC countries with a tobacco tax share below 25% are also the countries where, on average, cigarette prices are the lowest (USD PPP 4.6). For the under-performers, the tax share R indicator performs better in signalling the ineffectiveness of tobacco tax policies.
Total indirect taxes as % of the retail price of the most sold brand of cigarettes, 2022
Note: Total indirect taxes include excise taxes, VAT, import duties, and any other indirect taxes. The most sold brand of cigarettes is determined based on national market share information and varies across countries.
Source: WHO report on the global tobacco epidemic (WHO, 2023[33]).
Total indirect taxes and pre-tax prices in USD PPP, for the most sold brand of cigarettes, 2022
Note: Total indirect taxes include excise taxes, VAT, import duties, and any other indirect taxes. Pre-tax prices are defined as the retail price for a pack of 20 cigarettes of the most sold brand minus the indirect taxes levied on this brand. Prices in USD PPP are based on the implied PPP conversion rate from the International Monetary Fund (IMF) World Economic Outlook Database (October 2023). Cuba has been excluded due to missing USD PPP implied conversion rate. The most sold brand of cigarettes is determined based on national market share information and varies across countries.
Source: WHO report on the global tobacco epidemic (WHO, 2023[33]); IMF World Economic Outlook Database (IMF, 2023[37]).
In order to measure the effectiveness of tobacco tax policies and reforms, the MPOWER R indicator has to be complemented with an indicator that measures the affordability of tobacco products. There is not necessarily a positive correlation between the tax share and cigarette prices (Chaloupka et al., 2021[38]). Moreover, the tobacco tax share and cigarette prices do not provide sufficient information on consumer’s capacity to buy cigarettes. The tax share and the price level should therefore be complemented with an indicator of affordability. Against this background, the implementation of the MPOWER policy package includes information on the change in the affordability indicator between 2012 and 2022 (WHO, 2023[33]). The extent to which cigarettes are affordable is typically measured as the required GDP per capita to buy 2 000 cigarettes of the most sold brand (or the cheapest or premium brand) of cigarettes in a country and in a particular year (Blecher, 2020[39]). Cigarette affordability varies significantly in countries in LAC (Figure 1.14).
Tax shares and cigarette affordability are not positively correlated, on the contrary. For instance, in countries where the tax share exceeds 50%, cigarettes from the most sold brand are more affordable (4.2% of GDP per capita is required to purchase 2 000 cigarettes) than in countries with a tax share between 25-50% (6.2% of GDP per capita is required to purchase 2 000 cigarettes) (Figure 1.14). However, in countries where the tax share is the lowest, tobacco products are also the most affordable for all types of brands (Figure 1.14 and Figure 1.15).
Percentage of GDP per capita required to purchase 100 packs of 20 cigarettes of the most sold brand, 2022
Note: The affordability indicator measures the percentage of the country’s GDP per capita required to purchase 100 packs of 20 cigarettes. A higher percentage means lower affordability of cigarettes while a lower percentage means higher affordability. The most sold brand of cigarettes is determined based on national market share information and varies across countries.
Source: WHO report on the global tobacco epidemic (WHO, 2023[33]).
In countries with a larger tobacco tax share, tobacco markets are characterised, on average, by lower price dispersion (Figure 1.15). Higher price dispersion across cigarette brands provides smokers with more opportunities to trade down. Rather than to quit or reduce smoking, smokers (especially young people and lower-income population) might smoke cheaper products instead. In countries with a tax share above 50% are characterised, on average, by a lower degree of retail price dispersion than in countries where the tax share is between 25% and 50%, which can be explained by the more common ad valorem structures in countries with a tax share below 50% (see Table 3.1 in Chapter 3).
Percentage of GDP per capita required to purchase 100 packs of 20 cigarettes, 2022
Note: The affordability indicator measures the percentage of the country’s GDP per capita required to purchase 100 packs of 20 cigarettes. A higher percentage means lower affordability of cigarettes while a lower percentage means higher affordability. Affordability of the cheapest and premium brands are OECD calculations based on WHO report on the global tobacco epidemic (WHO, 2023[33]). The cheapest, most sold and premium brands of cigarettes are determined based on national market share information and can vary over time (i.e. the cheapest/most sold/premium brands of cigarettes in year 1 can be different from year 2) and across countries.
Source: Adapted from WHO report on the global tobacco epidemic (WHO, 2023[33]).
In most LAC countries, cigarettes have not become less affordable since 2012 (Table 1.4). Cigarettes have become less affordable in ten LAC countries between 2012 and 2022, but only in five countries (Bahamas, Colombia, Dominica, Honduras, Nicaragua) this can be linked to an increase in the tobacco tax share, while they became more affordable over the last ten years in two countries, including in Brazil despite the fact that the tax share in retail prices in Brazil exceeds the best practice of 75% (Table 1.3 and Figure 1.12). There are 14 countries in LAC where cigarettes have not become less affordable, and the tax share has not increased. Overall, this signals that there has been some progress albeit modest on average across the region.
The effectiveness of tobacco tax policy should be evaluated using a multitude of indicators rather than focusing only on the MPOWER R indicator. The relation between the changes in the tax share, retail prices and tobacco affordability are complex and depend on various factors, including tobacco tax reform, the tobacco industry’s response (or the absence thereof) to tax reforms and general price strategies, and nominal income growth in a jurisdiction (both inflation and real income growth) (IARC, 2008[40]; Drope, Siu and Chaloupka, 2022[41]). The interaction of these factors, and their impact on affordability and the tax share, which are considered in the cigarette tax scorecard, are discussed in Table 1.5, and this analysis is deepened in Chapter 5. Two key observations can be made:
If retail prices – either because of tax increases or pre-tax price increases – increase less than nominal income growth, cigarettes do not become less affordable.
Tax shares might decline even if taxes have increased if the increase in pre-tax retail prices exceeds the tax increase.
2012 to 2022
Note: Information included in this Table corresponds to the trends in tax share and affordability of the most sold brand of cigarettes. Tobacco tax share corresponds to the portion of total indirect taxes levied on a pack of 20 cigarettes, including excise taxes, VAT, import duties, and any other indirect taxes. The affordability indicator measures the percentage of the country’s GDP per capita required to purchase 100 packs of 20 cigarettes. A higher percentage means lower affordability of cigarettes while a lower percentage means higher affordability. To assess whether affordability changed on average since 2012, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data. The affordability of cigarettes was considered unchanged if the least squares trend in the per capita GDP required to purchase 2 000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were considered to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2 000 cigarettes was positive (negative) and significantly different from zero at the 5% level.
Source: WHO report on the global tobacco epidemic (WHO, 2023[33]).
Source: OECD.
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← 1. Short-term and long-term elasticity refer to the responsiveness of the quantity demanded to price changes over time (i.e. how individuals adjust their behaviour in relation to price changes). In this context, short-term elasticity of cigarettes might be inelastic as consumers may not immediately find substitutes for a product. Especially because cigarette consumption differs from other goods due to its addictive nature, elasticities tend to be particularly low, especially in the short run. However, in the long-term, cigarettes might become more elastic as consumers may find new alternatives, or producers may modify production.
← 2. E-cigarettes are electronic nicotine delivery systems (ENDS). They provide users with nicotine by transforming a liquid into vapor.