In most high-income countries and increasingly in low- and middle-income countries, tobacco use has become more concentrated among the least-educated, lowest-income populations [1,2]. As the World Health Organization describes, this creates a cycle of poverty and illness, where poor tobacco users divert spending from household necessities to spending on tobacco products, increase their likelihood of becoming sick and dying prematurely from tobacco use and, as a result, create greater economic hardship for themselves and their families [2].

In their paper in this issue of Addiction, Siahpush [3] and his colleagues show that, at least for cigarette smokers in high-income countries, financial stress increases interest in quitting smoking. This finding suggests that the dark cloud from the ongoing global economic downturn may have a silver lining, with many more smokers becoming increasingly motivated to quit. At the same time, however, Siahpush and his colleagues find that smokers facing financial stress are actually less likely to try to quit and, among those who do make a quit effort, less likely to do so successfully.

This financial stress is likely to increase, as governments adopt higher tobacco taxes in efforts to generate new revenues. In the United States, the federal cigarette excise tax was increased recently by nearly 62 cents per pack to almost $1.01 per pack, and taxes on other tobacco products were increased sharply; many states have recently or are seriously considering significant increases in state tobacco taxes. Given their effectiveness in generating new revenues [4], the same seems likely to happen in other countries.

While the evidence generally shows that tobacco use among those on low incomes will fall more in response to higher tobacco product taxes and prices [5–7], many low-income tobacco users will continue to use, increasing their financial stress and worsening the cycle of poverty and illness caused by tobacco. Efforts to avoid this and to take advantage of the greater interest in quitting among smokers facing financial stress are critical. In large part, success from so doing will depend upon how the new revenues from tax increases are used.

As Siahpush and his colleagues describe, one approach would be to use the new revenues to create or expand social programs that provide a safety net to those on low incomes. Such programs could include publicly provided health insurance for low-income families, food assistance programs and/or rent and utility subsidization programs. While these types of program would reduce financial stress among continuing smokers, they would do little to address directly the economic burden that smoking imposes upon low-income households.

Alternatively, new revenues could be used to support programs that help low-income smokers to quit successfully. Given the disconnection that Siahpush and colleagues have identified between interest and quitting and actual quit behavior and success for those facing financial stress, such programs would require reaching out more effectively to low-income smokers, better tailoring of behavioral counseling to the needs of smokers facing financial stress and the provision of appropriate pharmacotherapies. While much is known about effective interventions to promote cessation [8], Siahpush et al.'s findings suggest that much more needs to be done to reach proactively this particularly vulnerable, but ready to quit population. Modest investments in so doing will almost certainly generate substantial long-term public health and economic benefits.

Declaration of interest

Frank J. Chaloupka provides consultancy to Pfizer and GlaxoSmithKline pharmaceutical companies.