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

backgroundSince their introduction in 2014, heated tobacco products (HTPs) have entered a growing number of countries. However, few studies have systematically compared their affordability with that of cigarettes or examined differences in access across income groups. This study assessed the affordability of HTPs relative to combustible cigarettes with a focus on socioeconomic disparities.

methodsUsing publicly available data from the World Health Organization, World Bank, and industry sources, we compared retail prices, affordability, and tax shares across 55 countries with complete analytical data. Affordability was measured as the share of GDP per capita required to purchase 100 packs. Income distribution data were used to assess affordability across income quintiles.

resultsHTP sticks were more expensive than the most-sold cigarette brand in 23 countries and more expensive than the cheapest cigarette brand in 44 countries. In all 9 lower-middle-income countries and 10 of 16 upper-middle-income countries, HTPs were more expensive than the most-sold cigarette brand; in 24 of 30 high-income countries, they were cheaper. HTPs were not marketed in low-income countries. In lower-middle-income countries, purchasing 100 packs required 7.9% of GDP per capita for HTP sticks, compared with 5.3% for the most-sold cigarette brand and 3.5% for the cheapest brand. In high-income countries, the corresponding values were 1.6%, 1.9%, and 1.5%, respectively. For the lowest-income quintile across countries, purchasing 100 packs of HTPs required 9.1% of annual income, compared with 7.9% for the most-sold cigarette brand; for the highest-income quintile, the figures were 1.4% and 1.3%. Including device costs increased annual HTP use costs by 9.2-35.3%.

conclusionsHTPs were often less affordable than cigarettes, particularly in lower-income countries and among lower-income population groups. This pattern was not explained by higher taxes on HTP sticks; in most countries, HTPs had lower tax shares than cigarettes, but this did not consistently translate into lower retail prices. Assessments of HTP affordability should therefore consider observed consumer prices, upfront device costs, and within-country income differences, rather than tax rates alone.