Responses to Real-World and Hypothetical E-Cigarette Flavor Bans Among US Young Adults Who Use Flavored E-Cigarettes.

INTRODUCTION: E-cigarette flavor bans could reduce or exacerbate population health harms. To determine how US e-cigarette flavor restrictions might influence tobacco use behavior, this study assesses responses to real-world and hypothetical flavor bans among young adults who use flavored e-cigarettes. AIMS AND METHODS: An online, national survey of young adults ages 18-34 who use flavored e-cigarettes was conducted in 2021 (n = 1253), oversampling states affected by e-cigarette flavor restrictions. Participants were asked about their responses to real-world changes in the availability of flavored e-cigarettes. Unaffected participants were asked to predict their responses under a hypothetical federal e-cigarette flavor ban. RESULTS: The most common response to real-world changes in flavored e-cigarettes availability was to continue vaping (~80%). Among those who exclusively vaped, 12.5% switched to combustible tobacco. Quitting all forms of tobacco was selected by 5.3% of those exclusively vape versus 4.2% who dual use. Under a hypothetical federal ban, more than half of respondents stated they would continue vaping; 20.9% and 42.5% of those who exclusively vape versus dual use would use combustible tobacco. Quitting all tobacco products was endorsed by 34.5% and 17.2% of those who exclusively vape versus dual use. CONCLUSIONS: Young adults who vape flavored e-cigarettes have mixed responses to e-cigarette flavor bans. Under both real-world and hypothetical e-cigarette flavor bans, most who use flavored e-cigarettes continue vaping. Under a real-world ban, the second most common response among those who exclusively vape is to switch to smoking; under a hypothetical federal ban, it is to quit all tobacco. IMPLICATIONS: This is the first national survey to directly ask young adults who use flavored e-cigarettes about their responses to real-world changes in flavored e-cigarette availability due to state and local flavor restrictions. The survey also asked individuals to predict their responses under a hypothetical federal e-cigarette flavor ban. Most who use flavored e-cigarettes would continue vaping following e-cigarette flavor restrictions, but many would switch to or continue using combustible tobacco, highlighting potential negative public health consequences of these policies. Policymakers must consider the impact of e-cigarette flavor bans on both e-cigarette and cigarette use.

Responses to Real-World and Hypothetical Menthol Flavor Bans Among US Young Adults Who Smoke Menthol Cigarettes.

INTRODUCTION: Menthol cigarette bans have been implemented in some US states and localities, and a federal ban is being proposed by the FDA. This study asks how young adults who use menthol cigarettes respond to changes in menthol cigarette availability. AIMS AND METHODS: An online survey of young adults ages 18-34 who reported smoking menthol cigarettes on ≥7 of 30 days around Thanksgiving 2019 (n = 734), oversampling Massachusetts-the first state with a menthol ban. Participants reported their tobacco use behavior following real-world menthol cigarette bans or predicted their behavior under a hypothetical federal ban. RESULTS: Most respondents who exclusively smoked versus dual used with e-cigarettes continued smoking/using combustible tobacco following real-world bans (95.3% vs. 86.9%), accessing menthol cigarettes from other jurisdictions. Fewer who smoked exclusively responded by using e-cigarettes compared to those who dual used (3.9% vs. 43.7%). Quitting all tobacco use (ie, no smoking, vaping, or any tobacco use) was uncommon for both groups (3.6% vs. 9.0%). Under a hypothetical ban, majorities of those who exclusively smoke and who dual use predicted they would continue smoking (72.2% vs. 71.8%); fewer who smoke exclusively would use e-cigarettes compared to those who dual use (14.7% vs. 41.4%). Those who smoke exclusively were more likely to report quitting all tobacco compared to those who dual use (29.6% vs. 12.4%). CONCLUSIONS: Under real-world and hypothetical menthol cigarette bans, most respondents continued smoking. However, more young adults continued smoking following real-world bans, reflecting the limitations of local/state restrictions when menthol cigarettes are available in other jurisdictions. IMPLICATIONS: This survey asked young adults who use menthol cigarettes how they responded to real-world changes in the availability of menthol cigarettes; 89% reported continuing to smoke. Those who smoked exclusively were far less likely to respond by switching to e-cigarettes compared to people who dual used both products. Under a hypothetical federal menthol cigarette ban, 72% of young adults predicted that they would continue smoking. Quitting all tobacco was less common in the real-world scenario compared to the hypothetical ban. Access to menthol cigarettes in other jurisdictions and flavored cigars likely dampen the public health benefit of menthol cigarette bans.

Can decision field theory enhance our understanding of health-based choices? Evidence from risky health behaviors.

Discrete choice models are almost exclusively estimated assuming random utility maximization (RUM) is the decision rule applied by individuals. Recent studies indicate alternative behavioral assumptions may be more appropriate in health. Decision field theory (DFT) is a psychological theory of decision-making, which has shown promise in transport research. This study introduces DFT to health economics, empirically comparing it to RUM and random regret minimization (RRM) in risky health settings, namely tobacco and vaccine choices. Model fit, parameter ratios, choice shares, and elasticities are compared between RUM, RRM and DFT. Test statistics for model differences are derived using bootstrap methods. Decision rule heterogeneity is investigated using latent class models, including novel latent class DFT models. Tobacco and vaccine choice data are better explained with DFT than with RUM or RRM. Parameter ratios, choice shares and elasticities differ significantly between models. Mixed results are found for the presence of decision rule heterogeneity. We conclude that DFT shows promise as a behavioral assumption that underpins the estimation of discrete choice models in health economics. The significant differences demonstrate that care should be taken when choosing a decision rule, but further evidence is needed for generalizability beyond risky health choices.

Harm reduction for smokers with little to no quit interest: can tobacco policies encourage switching to e-cigarettes?

OBJECTIVE: A pressing tobacco policy concern is how to help smokers who have little interest in quitting cigarettes, a group that often suffers severe health consequences. By switching from cigarettes to e-cigarettes, they could obtain nicotine, potentially with less harm. We examined if policy-relevant attributes of cigarettes/e-cigarettes might encourage these smokers to switch to e-cigarettes. METHODS: An online survey and discrete choice experiment on a nationally-representative sample of adult smokers in the US who reported low interest in quitting (n=2000). We modelled preference heterogeneity using a latent class, latent variable model. We simulated policies that could encourage switching to e-cigarettes. RESULTS: Participants formed two latent classes: (1) those with very strong preferences for their own cigarettes; and (2) those whose choices were more responsive to policies. The latter group's choices were only somewhat responsive to menthol cigarette bans and taxes; the former group's choices were unresponsive. CONCLUSIONS: The policies studied seem unlikely to encourage harm reduction for individuals with little interest in quitting smoking.

Utility maximization versus regret minimization in health choice behavior: Evidence from four datasets.

Choice models in health are almost exclusively based on the neoclassical economic paradigm of utility maximization. Recently developed choice models have captured and shown empirical support for regret minimization as an alternative decision rule. In health economics, recent applications of RRM models indicate that individuals making health-based choices may exhibit regret minimization-type behavior. In this paper, we build on this research using a more flexible model that allows for heterogeneous decision rules, separately from preference heterogeneity, and comparing it to models that assume single decision rules. We use four datasets from diverse settings in which individuals make health choices: tobacco markets, genomic testing, and HIV prevention. We found that, if a one-size-fits-all rule is applied, then utility maximization was preferable to regret minimization for these datasets. However, we also find that individuals apply varying decision rules in similar proportions in these health settings, suggesting that models for heterogeneous decision rules were needed to capture these behaviors in these settings.

Information and sin goods: Experimental evidence on cigarettes.

We test the importance of information source on consumer choice in the context of sin goods, specifically electronic and tobacco cigarettes, among adult smokers. We proxy choice with intentions to vape and quit smoking in the next 30 days. We experimentally vary the information source: government, private companies, physicians, and no source. Our findings suggest that information source matters in the context of cigarettes choice for adult smokers. Private companies appear to be an important information source for cigarettes among adult smokers.

Kicking the habit is hard: A hybrid choice model investigation into the role of addiction in smoking behavior.

Use of choice models is growing rapidly in tobacco research. These models are being used to answer key policy questions. However, certain aspects of smokers' choice behavior are not well understood. One such feature is addiction. Here, we address this issue by modeling data from a choice experiment on the US smokers. We model addiction using a latent variable. We use this latent variable to understand the relationship between choices and addiction, giving attention to nicotine levels. We find that more addicted smokers have stronger preferences for cigarettes and are unwilling to switch to e-cigarettes. Addicted smokers value nicotine in tobacco products to a much greater extent than those that are less addicted. Lastly, we forecast short-term responses to lowering nicotine levels in cigarettes. The results suggest that current nicotine-focused policies could be effective at encouraging addicted smokers to less harmful products and lead to substantial public health gains.

Do JUUL and e-cigarette flavours change risk perceptions of adolescents? Evidence from a national survey.

INTRODUCTION: Use of JUULs and e-cigarettes is growing rapidly, particularly among adolescents. Research suggests that flavours may increase the appeal of these products, but little is known about how flavours influence perception. We examined whether youth perceptions about the health risks of JUULs and e-cigarettes vary with flavours. METHODS: We conducted a national survey in 2018 of 1610 high-school students aged 14-18 who had ever heard of either JUULs or e-cigarettes. Respondents were asked to rate the lung cancer risk, the harm of second-hand vapour, potential for addiction and healthiness of differently flavoured JUUL and e-cigarette products. We investigated the relationship among flavour, risk perception and socio-demographic information. RESULTS: We found that risk perceptions for both JUULs and e-cigarettes differ significantly by flavour type. Youths perceive fruit flavours to be less likely to lead to lung cancer (-0.909 (0.065)), have harmful second-hand vapour (-0.933 (0.060)) and be more addictive (1.104 (0.094)) relative to tobacco flavours. Candy, menthol/mint and alcohol flavours show similar patterns of risk association, although the magnitude is slightly smaller than for fruit flavours. CONCLUSIONS: Youths believe that flavours are related to the health risks of both JUULs and e-cigarettes despite the fact that these differences in risk by flavour have not been scientifically or systematically established. A policy concern is that misperceptions based on flavour may result in increased vaping by youths. The findings from this study support the assertion that banning fruit, menthol or mint and sweet flavours could reduce the appeal of JUULs and e-cigarettes to youth, with concomitant health protections.

Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment.

OBJECTIVES: To provide the policy-relevant estimates of impacts of alternative flavour bans on preferences and demand for cigarettes and e-cigarettes in adult smokers and recent quitters. METHODS: A best-best discrete choice experiment (DCE) is used to elicit smokers' and recent quitters' preferences for flavours, price, health impact and nicotine level in cigarettes and e-cigarettes. Choice of tobacco products and an opt-out option were examined. An efficient design yielded 36 choice sets. Exploded logit choice models were estimated. Flavour bans are modelled by restricting flavour coefficients in the estimated model. SETTING AND PARTICIPANTS: A sample of 2031 adult smokers and recent quitters was recruited to complete an online survey and DCE. RESULTS: Current smokers and recent quitters, on average, prefer cigarettes and menthol cigarettes over flavoured e-cigarettes. However, there is substantial preference heterogeneity by younger adults (ages 18-25), race/ethnicity and respondents with higher education. Our predictions suggest that a ban on menthol cigarettes would produce the greatest reduction in the choice of cigarettes (-5.2%), but with an accompanying increase in e-cigarettes use (3.8%). In contrast, banning flavours in e-cigarettes, while allowing menthol in cigarettes would result in the greatest increase in the selection of cigarettes (8.3%), and a decline in the use of e-cigarettes (-11.1%). A ban on all flavours, but tobacco in both products would increase 'opting-out' the most (5.2%) but would also increase choice of cigarettes (2.7%) and decrease choice of e-cigarettes (-7.9%). CONCLUSIONS: A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would likely be more effective in reducing the choice of cigarettes. A ban on all flavours in both products would likely reduce the smoking/vaping rates, but the use of cigarettes would be higher than in the status quo. Policy-makers should use these results to guide the choice of flavour bans in light of their stance on the potential health impacts both products.

What is the effect of bariatric surgery on health-related quality of life in people with obesity? observational cohort analysis of the United Kingdom national bariatric surgery registry.

BACKGROUND: Previous small studies investigating health-related quality of life (HRQoL) following bariatric surgery have demonstrated heterogenous effects. This study aimed to use National Bariatric Surgery Registry (NBSR) records to investigate the relationship between weight and HRQoL in people undergoing bariatric surgery in the UK. MATERIALS AND METHODS: In this observational study using United Kingdom National Bariatric Surgery Registry (NBSR) records between 1st June 2017 and 23rd November 2022, patients undergoing primary bariatric surgery with one baseline and at least one follow-up visit within one year from surgery were eligible for inclusion. Models estimated the relationship between EuroQol Five Dimension 5-level (EQ-5D) and BMI at baseline and longitudinally. Further analyses stratified by type 2 diabetes, type of operation (adjustable gastric band, sleeve, or bypass) and domain of EQ-5D. RESULTS: 5,587 observations of 2,160 patients were analysed. At baseline, mean BMI was 45.7±7.8 kg/m2 and mean EQ-5D was 0.78±0.22. A 1 kg/m2 higher BMI was associated with 0.005 (95%CI[-0.006,-0.004]) lower EQ-5D. In the month following surgery, EQ-5D increased to 0.91±0.2 while BMI decreased to 39.8±7.1 kg/m2 (P<0.001 for both); subsequently EQ-5D plateaued (0.90±0.17 at 12 months) while BMI continued to decrease (31.5±6.2 kg/m2 at 12 months, P<0.001). Each 1 kg/m2 decrease in BMI was associated with a 0.006 (95%CI [-0.007,-0.005]) increase in EQ-5D. Remission of T2D was independently associated with increase in EQ-5D (0.037, 95%CI [0.015,0.059]); type of operation was not. Decreases in BMI were associated with improvements in all five domains of EQ-5D. CONCLUSIONS: In this large dataset, greater weight loss and T2D remission were independently associated with greater improvements in HRQoL following bariatric surgery. The HRQoL-BMI relationship for people undergoing bariatric surgery differs to that which has previously been estimated following behavioural interventions. Use of the estimates generated here will be important for clinical and political decision making.

Defining treatment success in children with surgical conditions.

OBJECTIVES: Develop a score summarising how successfully a child with any surgical condition has been treated, and test the clinical validity of the score. DESIGN: Discrete choice experiment (DCE), and secondary analysis of data from six UK-wide prospective cohort studies. PARTICIPANTS: 253 people with lived experience of childhood surgical conditions, 114 health professionals caring for children with surgical conditions and 753 members of the general population completed the DCE. Data from 1383 children with surgical conditions were used in the secondary analysis. MAIN OUTCOME MEASURES: Normalised importance value of attribute (NIVA) for number/type of operations, hospital-treated infections, quality of life and duration of survival (reference attribute). RESULTS: Quality of life and duration of survival were the most important attributes in deciding whether a child had been successfully treated. Parents, carers and previously treated adults placed equal weight on both attributes (NIVA=0.996; 0.798 to 1.194). Healthcare professionals placed more weight on quality of life (NIVA=1.469; 0.950 to 1.987). The general population placed more weight on survival (NIVA=0.823; 95% CI 0.708 to 0.938). The resulting score (the Children's Surgery Outcome Reporting (CSOR) Treatment Success Score (TSS)) has the best possible value of 1, a value of 0 describes palliation and values less than 0 describe outcomes worse than palliation. CSOR TSSs varied clinically appropriately for infants whose data were included in the UK-wide cohort studies. CONCLUSIONS: The CSOR TSS summarises how successfully children with surgical conditions have been treated, and can therefore be used to compare hospitals' observed and expected outcomes.

Identifying Preferred Features of Weight Loss Programs for Adults With or at Risk of Type 2 Diabetes: A Discrete Choice Experiment With 3,960 Adults in the U.K.

OBJECTIVE: To understand preferences for features of weight loss programs among adults with or at risk of type 2 diabetes in the U.K. RESEARCH DESIGN AND METHODS: We conducted a discrete choice experiment with 3,960 U.K. adults living with overweight (n = 675 with type 2 diabetes). Preferences for seven characteristics of weight loss programs were analyzed. Simulations from choice models using the experimental data predicted uptake of available weight loss programs. Patient groups comprising those who have experience with weight loss programs, including from minority communities, informed the experimental design. RESULTS: Preferences did not differ between individuals with and without type 2 diabetes. Preferences were strongest for type of diet. Healthy eating was most preferred relative to total diet replacement (odds ratio [OR] 2.24; 95% CI 2.04-2.44). Individual interventions were more popular than group interventions (OR 1.40; 95% CI 1.34-1.47). Participants preferred programs offering weight loss of 10-15 kg (OR 1.37; 95% CI 1.28-1.47) to those offering loss of 2-4 kg. Online content was preferred over in-person contact (OR 1.24; 95% CI 1.18-1.30). There were few differences in preferences by gender or ethnicity, although weight loss was more important to women than to men, and individuals from ethnic minority populations identified more with programs where others shared their characteristics. Modeling suggested that tailoring programs to individual preferences could increase participation by ∼17 percentage points (68% in relative terms). CONCLUSIONS: Offering a range of weight loss programs targeting the preferred attributes of different patient groups could potentially encourage more people to participate in weight loss programs and support those living with overweight to reduce their weight.

Health Care Costs After Genome-Wide Sequencing for Children With Rare Diseases in England and Canada.

Importance: Etiologic diagnoses for rare diseases can involve a diagnostic odyssey, with repeated health care interactions and inconclusive diagnostics. Prior studies reported cost savings associated with genome-wide sequencing (GWS) compared with cytogenetic or molecular testing through rapid genetic diagnosis, but there is limited evidence on whether diagnosis from GWS is associated with reduced health care costs. Objective: To measure changes in health care costs after diagnosis from GWS for Canadian and English children with suspected rare diseases. Design, Setting, and Participants: This cohort study was a quasiexperimental retrospective analysis across 3 distinct English and Canadian cohorts, completed in 2023. Mixed-effects generalized linear regression was used to estimate associations between GWS and costs in the 2 years before and after GWS. Difference-in-differences regression was used to estimate associations of genetic diagnosis and costs. Costs are in 2019 US dollars. GWS was conducted in a research setting (Genomics England 100 000 Genomes Project [100KGP] and Clinical Assessment of the Utility of Sequencing and Evaluation as a Service [CAUSES] Research Clinic) or clinical outpatient setting (publicly reimbursed GWS in British Columbia [BC], Canada). Participants were children with developmental disorders, seizure disorders, or both undergoing GWS between 2014 and 2019. Data were analyzed from April 2021 to September 2023. Exposures: GWS and genetic diagnosis. Main Outcomes and Measures: Annual health care costs and diagnostic costs per child. Results: Study cohorts included 7775 patients in 100KGP, among whom 788 children had epilepsy (mean [SD] age at GWS, 11.6 [11.1] years; 400 female [50.8%]) and 6987 children had an intellectual disability (mean [SD] age at GWS, 8.2 [8.4] years; 2750 female [39.4%]); 77 patients in CAUSES (mean [SD] age at GWS, 8.5 [4.4] years; 33 female [42.9%]); and 118 publicly reimbursed GWS recipients from BC (mean [SD] age at GWS, 5.5 [5.2] years; 58 female [49.2%]). GWS diagnostic yield was 143 children (18.1%) for those with epilepsy and 1323 children (18.9%) for those with an intellectual disability in 100KGP, 47 children (39.8%) in the BC publicly reimbursed setting, and 42 children (54.5%) in CAUSES. Mean annual per-patient spending over the study period was $5283 (95% CI, $5121-$5427) for epilepsy and $3373 (95% CI, $3322-$3424) for intellectual disability in the 100KGP, $724 (95% CI, $563-$886) in CAUSES, and $1573 (95% CI, $1372-$1773) in the BC reimbursed setting. Receiving a genetic diagnosis from GWS was not associated with changed costs in any cohort. Conclusions and Relevance: In this study, receiving a genetic diagnosis was not associated with cost savings. This finding suggests that patient benefit and cost-effectiveness should instead drive GWS implementation.

Association between health insurance cost-sharing and choice of hospital tier for cardiovascular diseases in China: a prospective cohort study.

Background: Hospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers. Methods: In a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009-2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics. Findings: About 64-68% of stroke and IHD cases in urban areas and 27-29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas. Interpretation: Patient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use. Funding: Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.

Derivation of a UK preference-based value set for the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) to allow estimation of Mental Well-being Adjusted Life Years (MWALYs).

BACKGROUND: The Mental Well-being Adjusted Life Year (MWALY) is an alternative outcome measure to the quality-adjusted life year (QALY) in economic evaluations of interventions aimed at improving mental well-being. However, there is a lack of preference-based mental well-being instruments for capturing population mental well-being preferences. OBJECTIVES: To derive a UK preference-based value set for the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). METHODS: 225 participants that were interviewed between December 2020 and August 2021 completed 10 composite time trade-off (C-TTO) and 10 discrete choice experiment (DCE) interviewer-administered exercises. Heteroskedastic Tobit and conditional logit models were used to model C-TTO and DCE responses respectively. The DCE utility values were rescaled to a C-TTO comparable scale through anchoring and mapping. An inverse variance weighting hybrid model (IVWHM) was used to derive weighted-average coefficients from the modelled C-TTO and DCE coefficients. Model performance was assessed using statistical diagnostics. RESULTS: The valuation responses confirmed the feasibility and face validity of the C-TTO and DCE techniques. Apart from the main effects models, statistically significant associations were estimated between the predicted C-TTO value and participants' SWEMWBS scores, gender, ethnicities, education levels, and the interaction terms between age and useful feeling. The IVWHM was the most optimal model with the fewest logically inconsistent coefficients and the lowest pooled standard errors. The utility values generated by the rescaled DCE models and the IVWHM were generally higher than those of the C-TTO model. The predictive ability of the two DCE rescaling methods was similar according to the mean absolute deviation and root mean square deviation statistics. CONCLUSIONS: This study has produced the first preference-based value set for a measure of mental well-being. The IVWHM provided a desirable blend of both C-TTO and DCE models. The value set derived by this hybrid approach can be used for cost-utility analyses of mental well-being interventions.

COVID-19 vaccination, risk-compensatory behaviours, and contacts in the UK.

The physiological effects of vaccination against SARS-CoV-2 (COVID-19) are well documented, yet the behavioural effects not well known. Risk compensation suggests that gains in personal safety, as a result of vaccination, are offset by increases in risky behaviour, such as socialising, commuting and working outside the home. This is potentially important because transmission of SARS-CoV-2 is driven by contacts, which could be amplified by vaccine-related risk compensation. Here, we show that behaviours were overall unrelated to personal vaccination, but-adjusting for variation in mitigation policies-were responsive to the level of vaccination in the wider population: individuals in the UK were risk compensating when rates of vaccination were rising. This effect was observed across four nations of the UK, each of which varied policies autonomously.

Trends in all-cause mortality among adults with diagnosed type 2 diabetes in West Malaysia: 2010 - 2019.

AIMS: We determined 10-year all-cause mortality trends in diagnosed type 2 diabetes (T2D) population in West Malaysia, a middle-income country in the Western-Pacific region. METHODS: One million T2D people aged 40-79 registered in the National Diabetes Registry (2009-2018) were linked to death records (censored on 31 December 2019). Standardized absolute mortality rates and standardized mortality ratios (SMRs) were estimated relative to the Malaysian general population, and standardized to the 2019 registry population with respect to sex, age group, and disease duration. RESULTS: Overall all-cause standardized mortality rates were unchanged in both sexes. Rates increased in males aged 40-49 (annual average percent change [AAPC]: 2.46 % [95 % CI 0.42 %, 4.55 %]) and 50-59 (AAPC: 1.91 % [95 % CI 0.73 %, 3.10 %]), and females aged 40-49 (AAPC: 3.39 % [95 % CI 1.32 %, 5.50 %]). In both sexes, rates increased among those with 1) > 15 years disease duration, 2) prior cardiovascular disease, and 3) Bumiputera (Malay/native) ethnicity. The overall SMR was 1.83 (95 % CI 1.80, 1.86) for males and 1.85 (95 % CI 1.82, 1.89) for females, being higher in younger age groups and showed an increasing trend in those with either > 15 years disease duration or prior cardiovascular disease. CONCLUSIONS: Mortality trends worsened in certain T2D population in Malaysia.

Using stated-preferences methods to develop a summary metric to determine successful treatment of children with a surgical condition: a study protocol.

INTRODUCTION: Wide variation in the management of key paediatric surgical conditions in the UK has likely resulted in outcomes for some children being worse than they could be. Consequently, it is important to reduce unwarranted variation. However, major barriers to this are the inability to detect differences between observed and expected hospital outcomes based on the casemix of the children they have treated, and the inability to detect variation in significant outcomes between hospitals. A stated-preference study has been designed to estimate the value key stakeholders place on different elements of the outcomes for a child with a surgical condition. This study proposes to develop a summary metric to determine what represents successful treatment of children with surgical conditions. METHODS AND ANALYSIS: Preferences from parents, individuals treated for surgical conditions as infants/children, healthcare professionals and members of the public will be elicited using paired comparisons and kaizen tasks. A descriptive framework consisting of seven attributes representing types of operations, infections treated in hospital, quality of life and survival was identified. An experimental design has been completed using a D-efficient design with overlap in three attributes and excluding implausible combinations. All participants will be presented with an additional choice task including a palliative scenario that will be used as an anchor. The survey will be administered online. Primary analysis will estimate a mixed multinomial logit model. A traffic light system to determine what combination of attributes and levels represent successful treatment will be created. ETHICS AND DISSEMINATION: Ethics approval to conduct this study has been obtained from the Medical Sciences Inter-Divisional Research Ethics Committee (IDREC) at the University of Oxford (R59631/RE001-05). We will disseminate all of our results in peer-review publications and scientific presentations. Findings will be additionally disseminated through relevant charities and support groups and professional organisations.

Malaysian public preferences and decision making for COVID-19 vaccination: A discrete choice experiment.

Background: Low vaccine uptake has the potential to seriously undermine COVID-19 vaccination programs, as very high coverage levels are likely to be needed for virus suppression to return life to normal. We aimed to determine the influence of vaccine attributes (including access costs) on COVID-19 vaccination preferences among the Malaysian public to improve national uptake. Methods: An online Discrete Choice Experiment (DCE) was conducted on a representative sample of 2028 Malaysians. Respondents were asked to make vaccination decisions in a series of hypothetical scenarios. A nested, mixed logit model was used to estimate the preferences for vaccination over vaccine refusal and for how those preferences varied between different sub-populations. The attributes were the risk of developing severe side effects of the vaccine, vaccine effectiveness, vaccine content, vaccination schedule, and distance from home to vaccination centre. Findings: Reported public uptake of COVID-19 vaccination was primarily influenced by the risk of developing severe side effects (b = -1·747, 95% CI = -2·269, -1·225), vaccine effectiveness (b = 3·061, 95% CI = 2·628, 3·494) and its Halal status (b = 3·722, 95% CI = 3·152, 4·292). Other factors such as appointment timing and travel distance to the vaccination centre also had an effect on vaccine uptake. There was substantial heterogeneity in preferences between different populations, particularly for age groups, ethnicity, regions, and underlying health conditions. Interpretation: Perceived effectiveness and side effects are likely to affect COVID-19 vaccine uptake in Malaysia. Halal content is critical to Malays' vaccination choices. Reducing the physical distance to vaccination centres, particularly in rural areas where uptake is lower, is likely to improve uptake. Funding: Ministry of Health Research Grant from the Malaysian government [NIH/800-3/2/1 Jld.7(46), grant reference no: 57377 and warrant no: 91000776].

Who, me? Optimism bias about US teenagers' ability to quit vaping.

BACKGROUND AND AIMS: The vaping rate among US teenagers has doubled in the last 2 years, which may be explained in part by teenagers' optimism that they would have relatively little trouble in quitting. The aim of this study was to estimate the extent to which teenagers exhibited optimism bias, what characteristics are associated with optimism bias and which factors are related to respondents' perceptions of how hard it would be for them to quit. DESIGN: A national, on-line, cross-sectional survey in 2018 using quota sampling. SETTING: United States. PARTICIPANTS: Respondents were 1610 teenagers aged 14-18 years who had ever tried or heard of JUULs or e-cigarettes generally. MEASUREMENTS: Optimism bias was defined as respondents' perceptions of their own difficulty quitting vaping compared with that of an average US person of their own age. Linear regression was used to examine associations between respondents' characteristics with both optimism bias and their own perceived difficulty quitting vaping. FINDINGS: More than 60% of teenagers were optimistically biased about their ability to quit vaping. Smoking (b = -0.69, P < 0.01) and JUULing (b = -0.62, P < 0.01) were negatively associated with optimism bias but reduced-price school lunch eligibility (0.27, P = 0.02) and school satisfaction were positively associated (b = 0.05, P = 0.02). Smoking (b = 0.85, P < 0.01) was associated with an increased perception of the difficulty of quitting. That association was negative for black respondents (b = -0.81, P = 0.01) and those eligible for reduced-priced lunches (b = -0.48, P = 0.01), and positive for Hispanic respondents (b = 0.47, P = 0.04). CONCLUSIONS: On average, US teenagers appear to show optimism bias about their ability to quit vaping, which decreases with smoking and vaping and increases with eligibility for reduced-price school lunches.