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

GiorgiMzhavanadze2,3✉Phone+995 598 26 74 05Emailgiorgi@kachange.euEmailg.mzhavanadze@iset.geEmailg.mzhavanadze91@gmail.com

MAinEconomics1

1Knowledge-Action-Change8 Northumberland AvenueWC2N 5BYLondonUnited Kingdom

Healthy Initiatives (GO Zdorovi Iniciativi)36 Rustaveli Street01033KyivUkraine

32 0159, 63TbilisiMachavarianiGeorgia

Giorgi Mzhavanadze, ^z,2 MA in Economics

Affiliation 1: Knowledge-Action-Change, 8 Northumberland Avenue, London WC2N 5BY, United Kingdom

Affiliation 2: Healthy Initiatives (GO Zdorovi Iniciativi), 36 Rustaveli Street, Kyiv 01033, Ukraine

https://orcid.org/0000-0002-0336-311X

E-mail: giorgi@kachange.eu, g.mzhavanadze@iset.ge, g.mzhavanadze91@gmail.com

Tel: +995 598 26 74 05

Corresponding Author: Giorgi Mzhavanadze

Corresponding Author’s email: giorgi@kachange.eu, g.mzhavanadze@iset.ge, g.mzhavanadze91@gmail.com

^z,2 0159, Tbilisi, Georgia, Machavariani 63

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

Background

Since the introduction in 2014, heated tobacco products (HTPs) have become a significant and rapidly growing category within the global nicotine market. Initially launched in Japan and Italy, HTPs are now legally available in at least 70 countries as of early 2025, according to industry data [1, 2]. This expansion has been driven by substantial research and development investments, primarily from major tobacco companies [1]. Since 2020, the global market value of HTPs, including both consumables and heating devices, has exceeded that of nicotine vaping products, driven by rising prices and increasing consumer adoption. However, even with the number of users projected to increase from 21 million in 2020 to 55 million by 2026 (assuming roughly one device per user per year), HTP adoption still lags behind vaping, which is estimated to have 82 million users in 2024 [3]. According to market data, the highest growth rates have been observed in Europe and Asia, with some countries experiencing near one-to-one substitution for cigarettes (e.g., Hungary, South Korea, Italy, Germany), while in others, cigarette sales are declining faster than HTP uptake (e.g., Slovakia, Japan, Greece) [3].

However, this global expansion has been uneven. As of April 2025, HTPs were available in 40 high-income countries (HICs), 21 upper-middle-income countries (UMICs), and only 9 lower-middle-income countries (LMICs) [2]. Notably, they are not legally available in any low-income countries (LICs), highlighting a significant disparity in access based on national income levels.

This study is positioned within the public health framework of tobacco harm reduction, which advocates for providing safer nicotine alternatives to adult smokers who are unable or unwilling to quit. The principle of harm reduction is based on the understanding that the most severe health consequences of smoking arise from the toxicants produced during the combustion of tobacco, not from nicotine itself. HTPs operate by heating tobacco to a temperature sufficient to release a nicotine-containing aerosol, but without burning it. This process means they contain fewer harmful chemicals than tobacco smoke [4] and significantly reduce the formation of harmful and potentially harmful constituents. Clinical studies have consistently shown that smokers who switch exclusively to HTPs have a significant reduction in exposure to these toxicants [5–8]. Furthermore, switching to HTPs eliminates elevated exhaled carbon monoxide levels, with normalization observed rapidly [9, 10]. Recent research suggests that after adjusting for prior smoking history, the odds ratio for chronic obstructive pulmonary disease drops significantly among exclusive HTP users [11].

Despite a growing body of evidence suggesting that HTPs are a less harmful alternative to combustible cigarettes, both their absolute risk and the extent of relative risk reduction remain subjects of debate and ongoing research. The long-term health and mortality impacts of HTP use remain unknown [12, 13]. Also, to the best of our knowledge, no population-level observational studies have demonstrated a decline in smoking-related mortality in countries with high HTP uptake.

Given these uncertainties, this paper does not assess the health outcomes of HTPs. Instead, it focuses on the critical role of economic accessibility in realizing any potential public health benefits. Ensuring that less harmful products are accessible to all is a cornerstone of health equity [14]. If safer alternatives are not affordable for the populations most burdened by smoking-related diseases, often those in lower socioeconomic strata, their potential to reduce harm at a population level is severely limited [15–18]. Affordability, therefore, is not merely an economic consideration but a prerequisite for equitable harm reduction.

In this context, the relative price of HTPs compared to cigarettes becomes a critical determinant of consumer behavior. Economic evidence shows that raising cigarette prices through taxation reduces smoking prevalence, despite cigarette demand being relatively inelastic [19–22]. By contrast, emerging research suggests that HTP demand is more price-sensitive and these products function as economic substitutes for cigarettes [23, 24]. Alongside price, consumer uptake is also shaped by perceived relative health risks, peer influence, and motivations to quit or cut down [25, 26].

Early studies found that HTPs, despite benefiting from lower tax rates, were still priced higher than cigarettes in many countries [27]. The substantial upfront cost of purchasing a heating device has also been identified as a significant financial barrier, discouraging smokers from switching [28].

While previous research offered an initial cross-country comparison of HTP affordability, this paper is the first to focus explicitly on income-related disparities. It also considers how tax structures and market pricing shape access. By centering on economic equity, this paper provides evidence to guide fiscal and market interventions that could enhance the harm reduction potential of HTPs. To achieve this, we conducted a cross-country analysis of HTP affordability relative to cigarettes, incorporating both national and within-country income differences, as described in the Methods section below.

Methods

This cross-sectional study compared the affordability of HTPs and combustible cigarettes across 55 countries. Analyses were conducted by national income level, using the World Bank classification, and across income quintiles within each country.

The data for this study were compiled from multiple public and industry sources. Retail prices and tax burdens for the most-sold, premium, and cheapest cigarette brands, along with the most-sold brand of HTP sticks, were obtained from the World Health Organization’s (WHO) Global Health Observatory for 2022 [29]. As prices for HTP heating devices were not included in this dataset, they were supplemented with industry-reported data as of April 2024 [30]. Country-level macroeconomic indicators for 2022, including Gross Domestic Product (GDP) per capita and income distribution by quintiles, were sourced from the World Bank, while national income classifications followed the World Bank’s fiscal year 2024 groupings [31, 32].

The primary measure of affordability was the Relative Income Price (RIP), defined as the percentage of annual GDP per capita required to purchase 100 packs of a given product, with higher RIP values indicating lower affordability [33]. RIP was calculated for the general population and each income quintile. The analysis also incorporated the annualized cost of HTP heating devices, using the lowest- and highest-priced devices reported in April 2024, amortized over one year, and added this to HTP stick prices to capture the total annual cost of use. Tax burdens, expressed as the total tax share of the retail price, were also compared between HTP sticks and cigarettes.

Descriptive and comparative analyses were supplemented with ordinary least squares linear regression to examine associations between the HTP-cigarette price differential and factors such as cigarette prices, excise tax differentials, and GDP per capita. All calculations and statistical analyses were conducted in Microsoft Excel (Microsoft 365; Microsoft Corporation, Redmond, WA, USA).

Results

Cross-Country Price Comparison

Across the 55 countries analyzed, HTP sticks were more expensive than the most-sold brand of cigarettes in 26 countries and more expensive than the cheapest brand of cigarettes in 48 countries. This pattern varied by national income level: HTP sticks were more expensive than the most-sold cigarette brand in all 9 LMICs and 11 of the 16 UMICs in the sample. In contrast, among the 30 HICs, HTPs were less expensive than the most-sold cigarette brand in 24 countries.

Descriptive analysis indicated a negative relationship between absolute cigarette prices and the price differential between HTPs and cigarettes: in countries with higher cigarette prices, HTPs were more likely to be the cheaper option, and vice versa (Fig. 1).

Figure 1: Price Comparison Between Heated Tobacco Products And Cigarettes Across 55 Countries, 2022

Each point represents one country. Red squares plot the price of heated tobacco product (HTP) sticks against the price of the most-sold cigarette brand; purple diamonds plot HTP stick price against the cheapest cigarette brand (US$). The 45° parity line indicates equal prices; points above the line denote HTPs priced higher than the comparator cigarette brand and points below denote HTPs priced lower.. HTP device costs are not included in this figure.

Multiple linear regression confirmed this association. For every US$1 increase in the price of the most-sold cigarette brand, the price difference between HTPs and cigarettes decreased by approximately US$0.49 (95% CI: -0.5474 — -0.4305, p < 0.001). This suggests that HTP prices are not increasing at the same rate as cigarette prices; for every $1 rise in cigarette prices, HTP prices are associated with an increase of only about $0.51. The excise tax differential between the products showed no statistically significant association with the price differential.

Table 1
Linear Regression Results For Heated Tobacco Products Prices
Variable	Coefficient	Standard Error	t-statistic	P-value	95% CI
Intercept	1.3108***	0.1625	8.0654	< 0.0001	0.9845–1.6371
Tax differential	0.0052	0.0044	1.1926	0.2385	-0.0036–0.0141
Cigarette price	-0.4889***	0.0291	-16.7861	< 0.0001	-0.5474 – -0.4305
GDP per capita (US$1000)	0.0076**	< 0.0001	2.4774	0.0166	0.0014–0.0137
Ordinary least squares regression of HTP stick prices (US$) as the dependent variable, using 2022 cross-country data (n = 55). Independent variables: excise tax differential between cigarettes and HTP sticks, price of the most-sold cigarette brand, and GDP per capita (in US$1000). Adjusted R² = 0.8810. Cigarette price was strongly and negatively associated with HTP prices (p < 0.0001), GDP per capita had a small but statistically significant positive association, and the tax differential was not statistically significant. All monetary values are in US$. Coefficients are rounded to four decimal places. *p < 0.001, p < 0.05

CI: confidence interval; GDP: gross domestic product.

Affordability by National Income Level

Affordability varied substantially across income groups (Fig. 2). In LMICs, HTP sticks were, on average, 1.5 times less affordable than the most-sold cigarette brand and 2.3 times less affordable than the cheapest cigarettes. However, compared to premium brands, HTPs were 1.2 times more affordable. In UMICs, HTP affordability was comparable to premium cigarettes but 1.1 times lower than the most-sold brand. In HICs, HTP sticks were, on average, 1.2 times more affordable than the most-sold cigarettes and 1.3 times more affordable than premium brands. Across all groups, the cheapest cigarette brands remained the most affordable option. The affordability gap between HTPs and cigarettes narrowed as national income levels increased, making HTPs relatively more accessible in wealthier countries. No LICs in the dataset had HTP availability.

Figure 2 Affordability of Cigarettes and Heated Tobacco Products by Country Income Group, 2022

Bars show affordability as the Relative Income Price - the percentage of gross domestic product per capita required to purchase 100 packs. Product categories include the cheapest, most-sold, and premium cigarette brands; HTP sticks alone; HTP sticks + lowest-priced device; and HTP sticks + highest-priced device. Device costs are annualized over one year. Country groups are lower-middle-, upper-middle-, and high-income. Low-income countries had no legal HTP availability in the dataset.

GDP: gross domestic product; HTP: heated tobacco product.

Affordability by Income Quintile

Within countries, affordability gaps were most pronounced for lower-income groups (Fig. 3). For the lowest-income quintile across all countries, purchasing 100 packs of HTP sticks would require 9.2% of annual income, compared with 8.0% for the most-sold cigarette brand. Affordability improved steadily with rising income: for the highest-income quintile, the same purchase required 1.5% of annual income for HTPs and 1.3% for cigarettes. This translates to HTPs being 6.3 times less affordable for the poorest quintile compared with the richest. The disparity was particularly stark in LMICs, where the RIP for HTPs among the lowest-income quintile reached 24.9% of annual income (measured in GDP per capita).

Figure 3: Affordability of Cigarettes and Heated Tobacco Products Across Income Quintiles, 2022

Bars show affordability as the Relative Income Price (the percentage of gross domestic product per capita required to purchase 100 packs) for income quintiles within countries (Q1 = poorest 20%, Q5 = richest 20%). Values reflect averages across the 55-country sample. Product categories include the cheapest, most-sold, and premium cigarette brands; HTP sticks alone; HTP sticks + lowest-priced device; and HTP sticks + highest-priced device. Device costs are annualized over one year. Country groups are lower-middle-, upper-middle-, and high-income. Low-income countries had no legal HTP availability in the dataset.

GDP: gross domestic product; HTP: heated tobacco product.

Impact of Device Costs

Including the amortized annual cost of HTP devices increased the total annual cost of HTP use by 9.2–35.3%, depending on device model. When the cost of the cheapest device was included, HTPs became more expensive than the most-sold cigarette brand in 39 of the 55 countries, including all 9 LMICs and 14 of the 16 UMICs. When the most expensive device was factored in, HTPs were more expensive in 53 of 55 countries. The only exceptions where cigarettes remained costlier even with the highest-priced device were the United Kingdom and New Zealand.

Tax Burden Analysis

The higher price of HTPs did not appear to be driven by higher taxation. On the contrary, HTPs benefited from lower tax rates (measured as the share of total taxes in retail price) than cigarettes in 52 of the 55 countries studied. The average tax gap between cigarettes and HTPs was 24.3 percentage points. This tax advantage was largest in HICs (27.4 percentage points) and smallest in LMICs (16.5 percentage points). The regression analysis suggested that this tax differential was not being passed on to consumers in the form of lower retail prices, as the model found no statistically significant association between the size of the tax differential and the final price difference between HTP sticks and cigarettes (Table 1).

Discussion

This study highlights a substantial equity gap in global accessibility to HTPs. Both an expanding body of evidence and tobacco industry positioning present HTPs as potential harm reduction alternatives to smoking, yet affordability remains a major barrier, particularly for lower-income populations in low- and middle-income countries, which also bear a disproportionate burden of smoking-related disease.

The affordability gap appears to be driven primarily by industry pricing strategies rather than taxation. Despite having a lower tax burden than cigarettes in most countries, HTPs are frequently priced above cigarettes, consistent with prior findings that tax advantages are not fully reflected in retail prices [23, 27]. Across the major transnational tobacco companies, the highly publicized “transformation” narrative is best understood as a profit-maximizing corporate strategy rather than a genuine global shift away from combustible cigarettes. Evidence from corporate strategy analyses, leaked internal documents, and independent reviews shows that these shifts toward HTPs and other non-combustibles are concentrated in high-income countries where cigarette sales are already declining, regulation is stronger, and investor pressure encourages portfolio diversification [1, 34–39]. In these markets, alternative products are positioned as central to maintaining long-term profitability and market relevance, supported by marketing that frames them as premium, high-tech lifestyle products [34, 35, 37, 39]. By contrast, in lower-income countries, where cigarettes remain highly profitable and regulatory pressures are weaker, the industry continues to prioritize and aggressively market the deadliest form of nicotine delivery, combustible cigarettes [1, 38]. This dual strategy is consistent with industry commercial objectives and may support harm-reduction efforts in select high-income settings; however, it does not adequately address the needs of the majority of the global smoking population.

Another factor, particularly relevant in LMICs, is the relatively low price of cigarettes. In many such markets, taxes are not high enough to make cigarettes sufficiently expensive. In 2022, the average tax share on cigarettes was 73% in HICs versus 59% in LMICs. Our results show that higher cigarette prices are associated with greater relative affordability of HTPs. Where cigarettes remain inexpensive, there is limited scope and incentive for firms to price HTPs competitively. This reduces the financial motivation for consumers to switch.

Given these constraints, closing the affordability gap will likely require targeted policy interventions. One option is the use of price ceilings or profit-margin caps for HTPs, drawing on frameworks used in other sectors, such as pharmaceuticals, to improve affordability [40, 41]. While such measures may reduce retail prices, economic evaluations warn that price regulation can dampen innovation, risk supply shortages if caps are set too low, and spur illicit markets if controls are overly restrictive [42]. These trade-offs require careful design and implementation.

Conditional tax benefits are another potential tool. Preferential excise rates could be linked to a measurable retail price gap between HTPs and cigarettes, increasing the likelihood that tax advantages are passed on to consumers. Evidence from the investment tax incentive literature suggests that linking tax relief to specific performance outcomes can make such policies effective (43, 44). However, no country has yet applied this conditional approach to tobacco excise. Its implementation would present practical challenges, including monitoring compliance, verifying price information, and enforcing penalties for non-compliance.

Alongside fiscal measures, competition policy could also play a critical role in shaping market prices. Promoting competition may offer a more sustainable and economically efficient pathway to reducing HTP prices [41]. Easing regulatory barriers to entry for HTPs and other tobacco alternatives, and lifting product-specific prohibitions, can expand the number of suppliers, intensify price competition, and increase product variety. In countries where HTPs are either unavailable or limited to premium market segments, competition-oriented strategies may improve their affordability compared to cigarettes.

The initial cost of a heating device remains another significant barrier, echoing earlier research [28]. For smokers with limited disposable income, the upfront investment can represent several weeks or months’ worth of cigarette purchases. Even when stick prices are competitive, this fixed cost can effectively exclude lower-income smokers from trying or adopting HTPs.

Finally, our estimates likely understate the affordability gap by not accounting for roll-your-own (RYO) tobacco, which is the cheapest combustible option in many countries. Evidence shows RYO use is concentrated among lower socioeconomic groups because of its price advantage over factory-made cigarettes [46–50]. For smokers who use RYO, the price gap to switch to premium-priced HTPs is even higher than for manufactured cigarette smokers. Lower-income populations are also more price sensitive and more prone to downward substitution [48–51], exacerbating the equity problem: those with the fewest resources are the least exposed to any potential benefits of HTPs.

Limitations

This study has several limitations that should be acknowledged when interpreting the findings. First, it is based on cross-sectional data from 2022, providing only a single snapshot of market conditions. Tobacco and nicotine product markets are highly dynamic, with prices, taxes, and product availability subject to rapid changes in response to regulation, competition, and industry strategy. As such, the analysis is correlational and cannot establish causal relationships between price, tax structures, and consumer behavior.

Second, heating device cost estimates are drawn from a single company for 2024. While this may introduce some distortion, the potential bias is likely modest, as the company is the dominant market leader for HTPs in most observed markets. A comparison of heating device prices between 2024 and 2025 revealed no consistent pattern of price change, further suggesting that the figures used are a reasonable approximation.

Third, GDP per capita was used as the primary income indicator. Although it provides a broadly comparable measure across countries, it does not capture intra-country income inequality or differences in disposable income. This limitation was partially mitigated by examining income quintile data, but a more granular household-level analysis of income and expenditure would enable a more precise assessment of affordability and equity impacts.

Fourth, the analysis relies on WHO-reported tax share data, which measure the proportion of the retail price accounted for by all taxes on HTP sticks and cigarettes. While this metric provides a standardized international proxy, it does not capture the statutory excise tax rates set in national legislation. These rates may be ad valorem (a percentage of retail price), specific (a fixed amount per unit), or mixed. Consequently, HTPs and cigarettes could face identical statutory rates yet differ in measured tax share solely because of differences in retail prices. Under a specific tax, for example, a flat-rate levy will represent a smaller proportion of the price for higher-priced products. This limitation may introduce some imprecision in interpreting tax burdens; however, it should not critically affect our findings. The conclusion that tax advantages for HTPs are largely absorbed by manufacturers rather than passed on to consumers remains valid, regardless of whether measured differences in tax burden arise from statutory rates or underlying price levels.

Finally, as stated earlier, this study does not evaluate the health effects of HTPs or their effectiveness for smoking cessation. Its focus is strictly on the economic equity of access. The analysis assumes, based on existing evidence, that HTPs are significantly less harmful than combustible cigarettes and therefore have harm reduction potential. If this assumption were proven incorrect, or if the relative risk differential were minimal, the implications for health equity discussed here would not apply.

Conclusions

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. This pattern suggests incomplete pass-through of HTP tax advantages, potentially due to industry pricing strategies, which limits their impact on consumer prices. Policies that promote pass-through of any HTP tax advantages to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to substitute away from combustibles where such strategies are pursued. Without such action, the harm-reduction potential of HTPs may remain unevenly distributed, with lower-income populations continuing to bear the greatest burden of smoking-related disease. The analysis is cross-sectional and does not identify causal effects; results should be interpreted accordingly.

Abbreviations

GDP

Gross Domestic Product

HIC

High-Income Country

HTP

Heated Tobacco Product

LIC

Low-Income Country

LMIC

Lower-Middle-Income Country

RIP

Relative Income Price

RYO

Roll-Your-Own

UMIC

Upper-Middle-Income Country

WHO

World Health Organization

Electronic Supplementary Material

Below is the link to the electronic supplementary material

Supplementary Material 1

Supplementary Material 2

Supplementary Material 3

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Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Data Availability

The datasets analysed during the current study are available in the following repositories:•WHO Global Health Observatory:oNational taxes and retail price for 20 sticks of heated tobacco products [https://www.who.int/data/gho/data/indicators/indicator-details/GHO/national-taxes-and-retail-price-for-20-sticks-of-heated-tobacco-products]oNational taxes on a pack of 20 cigarettes [https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-tobacco-control-raise-taxes-national-taxes-pack-of-20]oRetail price for a pack of 20 cigarettes [https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-tobacco-control-raise-taxes-retail-price-for-a-pack-of-20-cigarettes]•World Bank Data:oGDP per capita (constant national currency) [https://data.worldbank.org/indicator/NY.GDP.PCAP.CN?view=chart]oGDP per capita (current US$) [https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?view=chart]oIncome shares by quintile: First [https://data.worldbank.org/indicator/SI.DST.FRST.20?view=chart]oSecond quintile [https://data.worldbank.org/indicator/SI.DST.02ND.20?view=chart]oThird quintile [https://data.worldbank.org/indicator/SI.DST.03RD.20?view=chart]oFourth quintile [https://data.worldbank.org/indicator/SI.DST.04TH.20?view=chart]oFifth quintile [https://data.worldbank.org/indicator/SI.DST.05TH.20?view=chart]oWorld Bank country and lending groups classification [https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups]•Industry data (Philip Morris International):oRetail selling price database – April 2024 release [https://www.pmi.com/resources/docs/default-source/investor_relation/may_2024---rsps.xlsx]oRetail selling price database – April 2025 release [https://www.pmi.com/resources/docs/default-source/investor_relation/apr25---rsps.xlsx]The compiled dataset used for analysis is available from the corresponding author on reasonable request.

Competing Interests

The author works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs.At the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons.In parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases.Both organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products.The charitable gift agreement (the “Pledge Agreement”) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization’s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking’s Certificate of Incorporation states that Global Action was formed to, among other things, “support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.” Global Action’s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website (www.globalactiontoendsmoking.org) and fully disclosed in public materials.This study was conducted as part of the author’s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above.

At the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons.

In parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases.

Both organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products.

The charitable gift agreement (the “Pledge Agreement”) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization’s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking’s Certificate of Incorporation states that Global Action was formed to, among other things, “support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.” Global Action’s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website (www.globalactiontoendsmoking.org) and fully disclosed in public materials.

This study was conducted as part of the author’s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above.

Funding

This study was funded with a grant from Global Action to End Smoking (formerly known as the Foundation for a Smoke-Free World), an independent U.S. nonprofit 501(c)(3) grantmaking organization. The funder had no role in the design, implementation, data analysis, interpretation of the study results, or preparation of this manuscript.

Author Contribution

GM contributed to the conceptualization, data collection, data analysis, and drafting of the manuscript. The author read and approved the final manuscript.

Acknowledgement

The author thanks the Global State of Tobacco Harm Reduction team at Knowledge-Action-Change for their support during the conceptualization and dissemination of this research. In particular, the author is grateful to Professor Gerry Stimson for his valuable feedback and for encouraging the initiation of this research from its earliest stages. The views expressed in this manuscript are solely those of the author.

Yes

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.