Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries

Abstract Background Since their introduction in 2014, heated tobacco products (HTPs) have entered a growing number of national markets. Despite this expansion, few studies have systematically compared their affordability with that of cigarettes or examined differences in access across income groups. Aims This study assesses the affordability of HTPs relative to combustible cigarettes across 55 countries of varying income levels, with a focus on disparities by socioeconomic status. Methods Using publicly available data from the World Health Organization, World Bank, and industry sources, we compared retail prices, affordability (measured as the share of GDP per capita required to purchase 100 packs), and tax burden (the share of all taxes in the retail price) across 55 countries. Income distribution data were incorporated to assess affordability across different economic strata. Results HTPs were absent from low-income countries. HTP sticks were more expensive than the most-sold cigarette brand in 26 countries and costlier than the cheapest cigarette brand in 48 countries. In all 9 lower-middle-income countries and 11/16 upper-middle-income countries, HTPs were more expensive than the most-sold brand; in 24/30 high-income countries they were cheaper. In lower-middle-income countries, HTPs were on average 1.5 times less affordable than the most-sold brand and 2.3 times less affordable than the cheapest cigarettes; in high-income countries they were 1.2 times more affordable than the most-sold brand. For the lowest-income quintile across countries, purchasing 100 packs of HTPs required 9.2% of annual income compared with 8.0% for cigarettes; for the highest-income quintile the figures were 1.5% and 1.3%, respectively. Including device costs increased annual HTP use costs by 9.2–35.3%. HTPs faced lower tax burden than cigarettes in 52 of 55 countries (mean gap: 24.3 percentage points), but this advantage was not reflected in retail prices. Conclusion Outside high-income countries, higher relative prices for HTPs remain a major barrier to their use as substitutes for cigarettes. Although average HTP tax shares were lower in most countries, observed retail prices did not consistently reflect this difference. Policies that promote pass-through to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to switch away from combustibles where such strategies are pursued.