{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T02:09:26Z","timestamp":1789697366759,"version":"4.0.1"},"reference-count":58,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2023,1,6]],"date-time":"2023-01-06T00:00:00Z","timestamp":1672963200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"African Capacity Building Foundation (funded by the Bill and Melinda Gates Foundation), through the Research Unit on the Economics of Excisable Products (REEP) at the University of Cape Town","award":["334"],"award-info":[{"award-number":["334"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Disparities in resources and access to material opportunities are important determinants of income-related health inequality. This paper hypothesises that the gradient of the inequality in health between the poor and the rich is likely to depend on differences in lifestyle practices including tobacco use and alcohol abuse. Using the 2015\/16 Namibia Household Income and Expenditure Survey and the Erreygers corrected concentration index, we estimate the effect of tobacco and alcohol use on income-related health inequalities. A decomposition technique was used to estimate the separate and joint contribution of tobacco and alcohol use to income-related health inequalities. The results indicate that tobacco use widens the income-related health inequality gap while alcohol consumption reduces health disparities. The simultaneous consumption of these goods has a stronger multiplicative effect on income-related health inequality. For instance, the simultaneous consumption of both goods contribute up to 1.03% of the inequality in health while tobacco use alone contributed only 0.6%. While policy options for each of these goods could be essential in reducing inequalities in health, there is a need to advocate additional measures that could simultaneously control the consumption of both goods.<\/jats:p>","DOI":"10.3390\/ijerph20021062","type":"journal-article","created":{"date-parts":[[2023,1,9]],"date-time":"2023-01-09T01:36:17Z","timestamp":1673228177000},"page":"1062","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Estimating Income-Related Health Inequalities Associated with Tobacco and Alcohol Consumption in Namibia"],"prefix":"10.3390","volume":"20","author":[{"given":"Martha Tangeni","family":"Nghipandulwa","sequence":"first","affiliation":[{"name":"Department of Economics, University of Namibia, Windhoek 13301, Namibia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1632-3341","authenticated-orcid":false,"given":"Alfred Kechia","family":"Mukong","sequence":"additional","affiliation":[{"name":"Department of Economics, University of Namibia, Windhoek 13301, Namibia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,1,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Lee, J.T., Hamid, F., Pati, S., Atun, R., and Millett, C. (2015). Impact of Non-Communicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0127199"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1136\/bmj.38142.554479.AE","article-title":"Mortality in relation to smoking: 50 years\u2019 observations on male British doctors","volume":"328","author":"Doll","year":"2004","journal-title":"BMJ"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e006993","DOI":"10.1136\/bmjopen-2014-006993","article-title":"Lung cancer in South Africa: A forecast to 2025 based on smoking prevalence data","volume":"5","author":"Winkler","year":"2015","journal-title":"BMJ Open"},{"key":"ref_4","unstructured":"World Health Organization (2020, March 21). Global Status Report on Alcohol and Health. Available online: https:\/\/www.who.int\/substance_abuse\/publications\/global_alcohol_report\/en\/."},{"key":"ref_5","unstructured":"World Health Organization (2020, November 22). Tobacco: Key Facts. Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/tobacco."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"820","DOI":"10.26719\/emhj.20.001","article-title":"Socioeconomic-related inequalities in self-rated health status in Kermanshah city, Islamic Republic of Iran: A decomposition analysis","volume":"26","author":"Rezaei","year":"2020","journal-title":"East. Mediterr. Health J."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Mukong, A.K. (2022). Estimating the Health Effect of Cigarette Smoking Duration in South Africa. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph192013005"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1136\/jech.2010.108977","article-title":"Decomposing socioeconomic inequality in self-rated health in Tehran","volume":"66","author":"Nedjat","year":"2012","journal-title":"J. Epidemiol. Community Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1186\/s12939-017-0598-7","article-title":"Lifestyle and Income-related Inequality in Health in South Africa","volume":"16","author":"Mukong","year":"2017","journal-title":"Int. J. Equity Health"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1186\/s12939-020-01361-7","article-title":"Income-related health inequalities associated with the coronavirus pandemic in South Africa: A decomposition analysis","volume":"20","author":"Nwosu","year":"2021","journal-title":"Int. J. Equity Health"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1016\/j.socscimed.2010.06.008","article-title":"The contribution of smoking and obesity to income-related inequalities in health in England","volume":"71","author":"Morris","year":"2010","journal-title":"Soc. Sci. Med."},{"key":"ref_12","unstructured":"Loring, B. (2014). Tobacco and Inequities\u2014Guiddance for Addressing Inequities in Tobacco-Related Harm, WHO Regional Office for Europe."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1257\/jep.13.2.145","article-title":"Healthy bodies and thick wallets: The dual relation between health and economic status","volume":"13","author":"Smith","year":"1999","journal-title":"J. Econ. Perspect."},{"key":"ref_14","first-page":"108","article-title":"Unravelling the SES: Health connection","volume":"30","author":"Smith","year":"2004","journal-title":"Popul. Dev. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1186\/1475-9276-11-73","article-title":"Decomposing socioeconomic inequalities in self-assessed health in Turkey","volume":"11","author":"Baydur","year":"2012","journal-title":"Int. J. Equity Health"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1016\/j.jhealeco.2004.02.001","article-title":"Socio-economic status, health and lifestyle","volume":"23","author":"Contoyannis","year":"2004","journal-title":"J. Health Econ."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1136\/tc.2010.037929","article-title":"Contribution of smoking-related and alcohol-related deaths to the gender gap in mortality: Evidence from 30 European countries","volume":"20","author":"McCartney","year":"2011","journal-title":"Tob. Control"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1093\/alcalc\/agt004","article-title":"The economic burden of alcohol dependence in Europe","volume":"48","author":"Kusel","year":"2013","journal-title":"Alcohol Alcohol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1093\/ntr\/ntaa162","article-title":"The economic cost of smoking in South Africa, 2016","volume":"23","author":"Boachie","year":"2021","journal-title":"Nicotine Tob. Res."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Manthey, J., Laram\u00e9e, P., Parrott, S., and Rehm, J. (2016). Economic burden associated with alcohol dependence in a German primary care sample: A bottom-up study. BMC Public Health, 16.","DOI":"10.1186\/s12889-016-3578-8"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1016\/j.neuro.2019.10.005","article-title":"Effects of chronic alcohol consumption and withdrawal on the cholinergic neurons of the pedunculopontine and laterodorsal tegmental nuclei of the rat: An unbiased stereological study","volume":"76","author":"Pereira","year":"2020","journal-title":"Neurotoxicology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1038\/nrcardio.2015.91","article-title":"Cardiovascular risks and benefits of moderate and heavy alcohol consumption","volume":"12","year":"2015","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1136\/tobaccocontrol-2015-052319","article-title":"Economic burden from smoking-related diseases in Thailand","volume":"25","author":"Bundhamcharoen","year":"2016","journal-title":"Tob. Control"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1032049","DOI":"10.1155\/2020\/1032049","article-title":"The dose-response relationship between alcohol consumption and the risk of type 2 diabetes among Asian men: A systematic review and meta-analysis of prospective cohort studies","volume":"2020","author":"Han","year":"2020","journal-title":"J. Diabetes Res."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Wu, S., Wang, R., Zhao, Y., Ma, X., Wu, M., Yan, X., and He, J. (2013). The relationship between self-rated health and objective health status: A population-based study. BMC Public Health, 13.","DOI":"10.1186\/1471-2458-13-320"},{"key":"ref_26","unstructured":"World Health Organization (2017). WHO Report on the Global Tobacco Epidemic 2017: Monitoring Tobacco Use and Prevention Policies, World Health Organization. Available online: https:\/\/apps.who.int\/iris\/handle\/10665\/255874."},{"key":"ref_27","unstructured":"World Health Organization (2015). WHO Global Report on Trends in Prevalence of Tobacco Smoking, World Health Organization. Available online: https:\/\/apps.who.int\/iris\/handle\/10665\/156262."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/s12939-019-0912-7","article-title":"Decomposition of socioeconomic inequalities in cigarette smoking: The case of Namibia","volume":"18","author":"Chisha","year":"2019","journal-title":"Int. J. Equity Health"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"He, Z., Bishwajit, G., and Yaya, S. (2019). Prevalence of alcohol and tobacco use among men and women in Namibia. Int. J. Environ. Res. Public Health, 16.","DOI":"10.3390\/ijerph16010059"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1136\/tobaccocontrol-2012-050725","article-title":"Tobacco control in Namibia: The importance of government capacity, media coverage and industry interference","volume":"23","author":"Tam","year":"2014","journal-title":"Tob. Control"},{"key":"ref_31","unstructured":"May, J., Carter, M., and Posel, D. (1995). The Composition and Persistence Of poverty in Rural South Africa: An Entitlements Approach, Johannesburg Land and Agriculture Policy Centre. Land and Agriculture Policy Centre Policy Paper No. 15."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1111\/j.1475-4991.1988.tb00564.x","article-title":"Equivalence scales, well-being, inequality, and poverty: Sensitivity estimates across ten countries using the Luxembourg income study (lis) database","volume":"34","author":"Buhmann","year":"1988","journal-title":"Rev. Income Wealth"},{"key":"ref_33","unstructured":"Woolard, I., and Leibrandt, M. (2022, November 21). Towards a Poverty Line for South Africa: Background Note\u2019, Southern Africa Labour and Development Research Unit, University of Cape Town, Available online: https:\/\/www.treasury.gov.za\/?aspxerrorpath=\/...\/povertyline\/Woolard%20Murray%202005%20Towards%20a."},{"key":"ref_34","first-page":"546","article-title":"Rising inequality? Changes in the distribution of income and consumption in the 1980\u2019s","volume":"82","author":"Cutler","year":"1992","journal-title":"Am. Econ. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"823","DOI":"10.1007\/s11069-012-0189-2","article-title":"Assessment of Social Vulnerability to Natural Disasters: A Comparative Study","volume":"63","author":"Yoon","year":"2012","journal-title":"Nat. Hazards"},{"key":"ref_36","first-page":"51","article-title":"Disaster Resilience Indicators for Benchmarking Baseline Conditions","volume":"7","author":"Cutter","year":"2010","journal-title":"J. Homel. Secur. Emerg. Manag."},{"key":"ref_37","first-page":"21","article-title":"Financial inclusion and household wellbeing in Namibia","volume":"25","author":"Mukong","year":"2021","journal-title":"S. Afr. Bus. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"102724","DOI":"10.1016\/j.forpol.2022.102724","article-title":"Institutions and environmental resource extraction within local communities in Mozambique","volume":"139","author":"Ntuli","year":"2022","journal-title":"For. Policy Econ."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.envsci.2021.11.010","article-title":"Institutional dynamics and forest use practices in the Santchou Landscape of Cameroon","volume":"128","author":"Kimengsi","year":"2022","journal-title":"Environ. Sci. Policy"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1136\/jech-2013-203306","article-title":"Income-related inequality in health and health-related behaviour: Exploring the equalisation hypotheses","volume":"68","author":"Hale","year":"2014","journal-title":"J. Epidemiol. Community Health"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1016\/0277-9536(91)90212-U","article-title":"On the measurement of inequalities in health","volume":"33","author":"Wagstaff","year":"1991","journal-title":"Soc. Sci. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1186\/1475-9276-10-48","article-title":"Socioeconomic-related health inequality in South Africa: Evidence from general household surveys","volume":"10","author":"Ataguba","year":"2011","journal-title":"Int. J. Equity Health"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1002\/hec.953","article-title":"The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality","volume":"14","author":"Wagstaff","year":"2005","journal-title":"Health Econ."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1016\/j.jhealeco.2008.02.003","article-title":"Correcting the concentration index","volume":"28","author":"Erreygers","year":"2009","journal-title":"J. Health Econ."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/S0304-4076(02)00161-6","article-title":"On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam","volume":"112","author":"Wagstaff","year":"2003","journal-title":"J. Econ."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1002\/hec.919","article-title":"Explaining income-related inequalities in doctor utilisation in Europe","volume":"13","author":"Doorslaer","year":"2004","journal-title":"Health Econ."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Erreygers, G., and Kessels, R. (2013). Regression-Based Decompositions of Rank-Dependent Indicators of Socioeconomic Inequality of Health, Health and Inequality, Emerald Group Publishing Limited.","DOI":"10.1108\/S1049-2585(2013)0000021010"},{"key":"ref_48","unstructured":"Ashenfelter, O., and Card, D. (2011). Decomposition Methods in Economics. Handbook of Labour Economics, Elsevier."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Kessels, R., and Erreygers, G. (2015). A Unified Structural Equation Modelling Approach for the Decomposition of Rank-Dependent Indicators of Socioeconomic Inequality of Health, United Nations University. Number 2015\/017, WIDER Working Paper.","DOI":"10.35188\/UNU-WIDER\/2015\/902-2"},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"O\u2019Donnell, O., van Doorslaer, E., Wagstaff, A., and Lindelow, M. (2008). Analysing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation, The World Bank.","DOI":"10.1596\/978-0-8213-6933-3"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/S0304-4076(96)01807-6","article-title":"Socioeconomic inequalities in health: Measurement, computation, and statistical inference","volume":"77","author":"Kakwani","year":"1997","journal-title":"J. Econom."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1093\/oxrep\/5.1.89","article-title":"Equity in the finance and delivery of health care: Some tentative cross-country comparisons","volume":"5","author":"Wagstaff","year":"1989","journal-title":"Oxf. Rev. Econ. Policy"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1257\/jel.41.1.113","article-title":"Health Inequality and Economic Development","volume":"41","author":"Deaton","year":"2003","journal-title":"J. Econ. Lit."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1002\/(SICI)1097-0215(19990827)82:5<657::AID-IJC7>3.0.CO;2-C","article-title":"Independent and Joint Effects of Tobacco Smoking and Alcohol","volume":"664","author":"Castellsague","year":"1999","journal-title":"Int. J. Cancer"},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Hart, C.L., Davey Smith, G., Gruer, L., and Watt, G.C. (2010). The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: A 30-year cohort study. BMC Public Health, 10.","DOI":"10.1186\/1471-2458-10-789"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1186\/s12955-021-01770-4","article-title":"Effects of illness perceptions on health-related quality of life in patients with rheumatoid arthritis in China","volume":"19","author":"Wang","year":"2021","journal-title":"Health Qual. Life Outcomes"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1186\/s12939-019-0909-2","article-title":"Measurement and decomposition of income-related inequality in self-rated health among the elderly in China","volume":"18","author":"Gu","year":"2019","journal-title":"Int. J. Equity Health"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1186\/s12939-021-01448-9","article-title":"Income-related health inequality among Chinese adults during the COVID-19 pandemic: Evidence based on an online survey","volume":"20","author":"Nie","year":"2021","journal-title":"Int. J. Equity Health"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/2\/1062\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:02:13Z","timestamp":1760119333000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/20\/2\/1062"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1,6]]},"references-count":58,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2023,1]]}},"alternative-id":["ijerph20021062"],"URL":"https:\/\/doi.org\/10.3390\/ijerph20021062","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1,6]]}}}