[What does the Brazilian National Health Survey have to say about the influence of cigarette spending on household income?] / O que a Pesquisa Nacional de Saúde tem a dizer sobre a influência do gasto com cigarro no rendimento domiciliar?

In a country whose indicators of population impoverishment continue to increase, it is concerning that individuals spend money to buy cigarettes instead of using this resource in actions that strengthen aspects of the well-being of their lives and that of their families. Based on the Brazilian National Health Survey conducted in 2019, the influence of spending on manufactured cigarettes on the family budget in households with at least one smoker was estimated, stratified by sociodemographic characteristics. Brazilian smokers allocated around 8% of their average per capita monthly household income to the purchase of manufactured cigarettes. The percentage of average monthly expenditure on cigarettes reached almost 10% of this income among smokers aged 15 to 24 and was even higher for those with incomplete elementary education (approximately 11%). In the North and Northeast regions of the country, this expenditure exceeded 9%. The state with the most significant impact on household income was Acre (13.6%), followed by Alagoas (11.9%), Ceará, Pará, and Tocantins (all with approximately 11%). Our findings, therefore, reinforce the importance of strengthening the implementation of effective measures, such as tax policy, to reduce the proportion of smokers. Thus, the money that individuals currently allocate to purchase cigarettes can be used to meet their basic needs, contributing to the promotion of health and improving the quality of life.

Em um Brasil no qual os indicadores de empobrecimento da população seguem aumentando, preocupa o fato de que indivíduos gastem dinheiro para comprar cigarro em vez de usarem esse recurso em ações que fortaleçam aspectos do bem-estar de suas jornadas de vida e de suas famílias. Estimou-se, a partir da Pesquisa Nacional de Saúde de 2019, a influência que o gasto com cigarro industrializado teve no orçamento familiar nos domicílios com pelo menos um fumante, estratificada por características sociodemográficas. Os fumantes brasileiros destinaram cerca de 8% do rendimento médio mensal domiciliar per capita para a compra de cigarros industrializados. O percentual do gasto médio mensal chegou a quase 10% desse rendimento, entre os fumantes de 15 a 24 anos, e foi ainda maior para aqueles com Ensino Fundamental incompleto (aproximadamente 11%). Nas regiões Norte e Nordeste do país, esse gasto ultrapassou os 9%. O estado com o maior comprometimento da renda domiciliar foi o Acre (13,6%), seguido por Alagoas (11,9%), Ceará, Pará e Tocantins (todos com aproximadamente 11%). Nossos achados reforçam, portanto, a importância de fortalecer a implementação de medidas efetivas de redução da proporção de fumantes, tal como a política tributária. Dessa forma, o dinheiro que atualmente é destinado pelos indivíduos à compra de cigarros poderá ser revertido no atendimento de suas necessidades básicas, contribuindo para a promoção da saúde e melhoria da qualidade de vida.

En un Brasil donde los indicadores de empobrecimiento de la población siguen aumentando, es preocupante el hecho de que las personas gasten dinero para comprar cigarrillo en lugar de usarlo en acciones para fortalecer los aspectos del bienestar de sus vidas y la de sus familias. A partir de la Encuesta Nacional de Salud brasileña realizada en 2019, se estimó la influencia del gasto en cigarrillo industrializado en el presupuesto familiar de los hogares donde vivía al menos un fumador, estratificado por características sociodemográficas. Los fumadores brasileños destinaron alrededor del 8% del ingreso per cápita mensual promedio del hogar para la compra de cigarrillos industrializados. El porcentaje del gasto mensual promedio en cigarrillos alcanzó casi el 10% de este ingreso entre los fumadores de 15 a 24 años y fue aún mayor para los que tenían educación primaria incompleta (aproximadamente el 11%). En el Norte y Nordeste del país, ese gasto superó el 9%. El estado con un mayor compromiso con los ingresos del hogar fue Acre (el 13,6%), seguido por Alagoas (el 11,9%), Ceará, Pará y Tocantins (todos con aproximadamente el 11%). Por lo tanto, nuestros resultados resaltan la importancia de fortalecer la implementación de medidas efectivas para reducir la proporción de fumadores, tal como la política tributaria. Así, el dinero que actualmente las personas destinan a la compra de cigarrillos podría utilizarse en la atención de sus necesidades básicas, contribuyendo a promover la salud y la mejora de la calidad de vida.

Cigarette Prices and Smoking Among Youth in 16 African Countries: Evidence From the Global Youth Tobacco Survey.

INTRODUCTION: African countries have among the lowest excise taxes in the world. This paper provides new evidence on the association between cigarette prices and youth smoking in 16 African countries. AIMS AND METHODS: We use Global Youth Tobacco Survey (GYTS) cross-country data from approximately 67 500 participants. The relationship between prices and youth smoking in Africa is estimated using probit models for smoking participation and generalized linear models for conditional cigarette demand. Each model is estimated using local-brand and foreign-brand cigarette prices. RESULTS: Higher prices are associated with lower demand across African countries, for both smoking prevalence and the intensity of cigarette consumption by smokers. The estimated price elasticity of participation is -0.70 [95% CI: -1.28 to -0.12] for local-brand cigarettes and -0.71 [95% CI: -0.98 to -0.44] for foreign-brand cigarettes. The price elasticity of conditional cigarette demand is -0.44 [95% CI: -0.76 to -0.12] for local brands and -0.75 [95% CI: -0.96 to -0.53] for foreign brands. The total price elasticity of demand for youth in our sample is -1.14 for local brands and -1.46 for foreign brands. CONCLUSIONS: Higher cigarette prices significantly decrease the likelihood of smoking and decrease the intensity of cigarette consumption among African youths. Increases in the excise tax that increase the retail price of cigarettes will play an important role in reducing youth tobacco use on the continent. Governments are encouraged to increase excise taxes in order to improve public health. IMPLICATIONS: Evidence on the association between cigarette prices and youth smoking in African countries is limited. The Global Youth Tobacco Survey (GYTS) was first introduced in 1999. In 2012, the Centers for Disease Control and Prevention revised the GYTS questionnaire, which removed some questions and introduced new questions into the survey. To the best of our knowledge, there are no published estimates of the relationship between cigarette prices and demand that have used this more recent individual-level GYTS data for African countries. In conducting this analysis, we add to the limited literature on the association between cigarette prices and youth smoking in Africa.

Genetic predispositions moderate the effectiveness of tobacco excise taxes.

BACKGROUND: Tobacco consumption is one of the leading causes of preventable death. In this study, we analyze whether someone's genetic predisposition to smoking moderates the response to tobacco excise taxes. METHODS: We interact polygenic scores for smoking behavior with state-level tobacco excise taxes in longitudinal data (1992-2016) from the US Health and Retirement Study (N = 12,058). RESULTS: Someone's genetic propensity to smoking moderates the effect of tobacco excise taxes on smoking behavior along the extensive margin (smoking vs. not smoking) and the intensive margin (the amount of tobacco consumed). In our analysis sample, we do not find a significant gene-environment interaction effect on smoking cessation. CONCLUSIONS: When tobacco excise taxes are relatively high, those with a high genetic predisposition to smoking are less likely (i) to smoke, and (ii) to smoke heavily. While tobacco excise taxes have been effective in reducing smoking, the gene-environment interaction effects we observe in our sample suggest that policy makers could benefit from taking into account the moderating role of genes in the design of future tobacco control policies.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

The evaluation of the smoking cessation behaviors of coal miners according to the health belief model: A cross-sectional study.

The aim of this descriptive and cross-sectional study was to evaluate smoking characteristics and smoking cessation behaviors among smoking coal miners according to the Health Belief Model (HBM). The population of this cross sectional study consisted of 582 coal miners, while the sample consisted of 473 miners who agreed to participate in the study. The miners working above ground obtained significantly higher scores compared to those who worked underground (p = 0.027). There was a significant positive correlation between smoking costs and perceived susceptibility (p < 0.001; r = 0.249) sub dimension scores, while smoking costs also had a weak positive correlation with perceived severity (p < 0.050; r = 0.179). In addition, many sub dimensions of the HBM-SCS were found to be correlated (p < 0.001). This finding shows that workers who have smoking costs may have made smoking cessation a strategic goal. Smoking habits are widespread among coal miners, and it was thought that further efforts should be made to explain to those coal miners the health hazards of smoking.

Cost-Effectiveness Analysis of Smoking Cessation Interventions in the United Kingdom Accounting for Major Neuropsychiatric Adverse Events.

OBJECTIVES: Smoking is a leading cause of death worldwide. Cessation aids include varenicline, bupropion, nicotine replacement therapy (NRT), and e-cigarettes at various doses (low, standard and high) and used alone or in combination with each other. Previous cost-effectiveness analyses have not fully accounted for adverse effects nor compared all cessation aids. The objective was to determine the relative cost-effectiveness of cessation aids in the United Kingdom. METHODS: An established Markov cohort model was adapted to incorporate health outcomes and costs due to depression and self-harm associated with cessation aids, alongside other health events. Relative efficacy in terms of abstinence and major adverse neuropsychiatric events was informed by a systematic review and network meta-analysis. Base case results are reported for UK-licensed interventions only. Two sensitivity analyses are reported, one including unlicensed interventions and another comparing all cessation aids but removing the impact of depression and self-harm. The sensitivity of conclusions to model inputs was assessed by calculating the expected value of partial perfect information. RESULTS: When limited to UK-licensed interventions, varenicline standard-dose and NRT standard-dose were most cost-effective. Including unlicensed interventions, e-cigarette low-dose appeared most cost-effective followed by varenicline standard-dose + bupropion standard-dose combined. When the impact of depression and self-harm was excluded, varenicline standard-dose + NRT standard-dose was most cost-effective, followed by varenicline low-dose + NRT standard-dose. CONCLUSION: Although found to be most cost-effective, combined therapy is currently unlicensed in the United Kingdom and the safety of e-cigarettes remains uncertain. The value-of-information analysis suggested researchers should continue to investigate the long-term effectiveness and safety outcomes of e-cigarettes in studies with active comparators.

Impact of price and non-price policies on household cigarette consumption and nutrient intake in smoking-tolerant Indonesia.

OBJECTIVE: To examine the impact of cigarette price and smoking environment on allocation of household expenditure and its implication on nutrition consumption. DESIGN: A cross-sectional study was conducted using the 2014 National Socioeconomic Survey (SUSENAS), the 2014 Village Potential Survey (PODES) and the 2013 Basic National Health Survey (RISKESDAS). SUSENAS and PODES data were collected by the Central Bureau of Statistics. RISKESDAS was conducted by National Institute of Health Research and Development (Balitbangkes), Indonesian Ministry of Health (MOH). SETTING AND PARTICIPANTS: The sample covered all districts in Indonesia; with sample size of 285 400 households. These households are grouped into low, medium and high smoking prevalence districts. PRIMARY AND SECONDARY OUTCOME MEASURES: The impact of cigarette price and smoking environment on household consumption of cigarette, share of eight food groups, as well as calorie and protein intake. RESULT: 1% increase in cigarette price will increase the cigarette budget share by 0.0737 points and reduce the budget share for eggs/milk, prepared food, staple food, nuts, fish/meat and fruit, from 0.0200 points (eggs/milk) up to 0.0033 points (fruit). Reallocation of household expenditure brings changes in food composition, resulting in declining calorie and protein intake. A 1% cigarette price increase reduces calorie and protein intake as much as 0.0885% and 0.1052%, respectively. On the other hand, existence of smoke-free areas and low smoking prevalence areas reduces the household budget for cigarettes. CONCLUSION: A pricing policy must be accompanied by non-pricing policies to reduce cigarette budget share.

The effects of tobacco control policies on global smoking prevalence.

Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development2. Here we show that comprehensive tobacco control policies-including smoking bans, health warnings, advertising bans and tobacco taxes-are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

One-Year Efficacy and Incremental Cost-effectiveness of Contingency Management for Cigarette Smokers With Depression.

INTRODUCTION: Contingency management (CM) is efficacious for smoking cessation. To date, the number of cost-effectiveness evaluations of behavioral and pharmacological smoking cessation treatments far outnumbers the ones on CM. This study estimated 1-year efficacy and incremental cost-effectiveness of adding CM in relation to abstinence outcomes for a cognitive-behavioral therapy (CBT)+behavioral activation (BA) treatment. METHODS: The study sample comprised 120 smokers with depression (% females: 70.8%; mean age: 51.67 [SD = 9.59]) enrolled in an 8-week randomized controlled clinical trial. Clinical effectiveness variables were point-prevalence abstinence, continuous abstinence, longest duration of abstinence (LDA), and Beck-Depression Inventory-II (BDI-II) scores at 1-year follow-up. Cost-effectiveness analyses were based on resource utilization, unit costs per patient, and incremental cost per additional LDA week at 1 year. RESULTS: There was a significant effect of time by treatment group interaction, which indicated superior effects of CBT+BA+CM across time. Point-prevalence abstinence (53.3% [32/60]) was superior in participants receiving CBT+BA+CM compared with those in CBT+BA (23.3% [14/60]), but both groups were equally likely to present sustained reductions in depression. The average cost per patient was €208.85 (US$236.57) for CBT+BA and €410.64 (US$465.14) for CBT+BA+CM, p < .001. The incremental cost of using CM to enhance 1-year abstinence by one extra LDA week was €18 (US$20.39) (95% confidence interval: 17.75-18.25). CONCLUSIONS: Behavioral treatments addressing both smoking and depression are efficacious for sustaining high quit rates at 1 year. Adding CM to CBT+BA for smoking cessation is highly cost-effective, with an estimated net benefit of €4704 (US$5344.80). IMPLICATIONS: Informing on the cost-effectiveness of CM might expedite the translation of research findings into clinical practice. Findings suggested that CM is feasible and highly cost-effective, confirming that its implementation is worthwhile. At a CM cost per patient of €410.64 (US$465.14), the net benefit equals €4704 (US$5344.80), although even starting from a minimum investment of €20 (US$22.72) was cost-effective. CLINICALTRIALS-GOV IDENTIFIER: NCT03163056.

The Economic Cost of Smoking in South Africa, 2016.

INTRODUCTION: Chronic, noncommunicable diseases are on the rise globally, with tobacco consumption being an important contributing risk factor. These increases result in significant economic costs due to increased healthcare costs, productive lives lost, and productive days lost due to illness. Estimates of these economic costs are scarce in low- and middle-income countries. METHODS: Drawing on a diverse range of data sources, direct healthcare costs, and productivity losses due to illness and premature deaths were estimated using the cost-of-illness approach. The present value of lifetime earnings was used to estimate productivity losses from premature deaths. RESULTS: We estimate that 25 708 deaths among persons aged 35-74 in 2016 are smoking-attributable. The economic cost of smoking was R42 billion (US$2.88 billion), of which R14.48 billion was for healthcare costs (hospitalization and outpatient department visits). The economic cost of smoking amounted to 0.97% of the South African GDP in 2016, while the healthcare cost of smoking-related diseases was 4.1% of total South African health expenditure. The costs are lower for women because of their lower smoking prevalence. CONCLUSION: The economic burden of smoking calls for a further scaling-up of tobacco-control interventions in South Africa. IMPLICATIONS: This article addresses the paucity of research on the detailed economic costs of smoking in low-and middle-income countries, including South Africa. Our calculations, based on an extensive range of recent data, provide the most detailed estimate to date and include quantification of the direct and indirect costs of smoking in South Africa. We found that the magnitude of the costs related to smoking in South Africa is larger than in the previous estimates and that for every Rand received in the form of cigarette tax, society loses 3.43 Rands. This article provides an economic case for evidence-based tobacco control in South Africa.

Independent Associations Between Different Measures of Socioeconomic Position and Smoking Status: A Cross-Sectional Study of Adults in England.

INTRODUCTION: To gain a better understanding of the complex and independent associations between different measures of socioeconomic position (SEP) and smoking in England. AIMS AND METHODS: Between March 2013 and January 2019 data were collected from 120 496 adults aged 16+ in England taking part in the Smoking Toolkit Study. Of these, 18.04% (n = 21 720) were current smokers. Six indicators of SEP were measured: social grade, employment status, educational qualifications, home and car ownership and income. Models were constructed using ridge regression to assess the contribution of each measure of SEP, taking account of high collinearity. RESULTS: The strongest predictor of smoking status was housing tenure. Those who did not own their own home had twice the odds of smoking compared with homeowners (odds ratio [OR] = 2.01). Social grade, educational qualification, and income were also good predictors. Those in social grades C1 (OR = 1.04), C2 (OR = 1.29), D (OR = 1.39), and E (OR = 1.78) had higher odds of smoking than those in social grade AB. Similarly, those with A-level/equivalent (OR = 1.15), GCSE/vocational (OR = 1.48), other/still studying (OR = 1.12), and no post-16 qualifications (OR = 1.48) had higher odds of smoking than those with university qualifications, as did those who earned in the lowest (OR = 1.23), third (OR = 1.18), and second quartiles (OR = 1.06) compared with those earning in the highest. Associations between smoking and employment (OR = 1.03) and car ownership (OR = 1.05) were much smaller. CONCLUSIONS: Of a variety of socioeconomic measures, housing tenure appears to be the strongest independent predictor of smoking in England, followed by social grade, educational qualifications, and income. Employment status and car ownership have the lowest predictive power. IMPLICATIONS: This study used ridge regression, a technique which takes into account high collinearity between variables, to gain a better understanding of the independent associations between different measures of SEP and smoking in England. The findings provide guidance as to which SEP measures one could use when trying to identifying individuals most at risk from smoking, with housing tenure identified as the strongest independent predictor.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication.

OBJECTIVE: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. METHODS: We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance. RESULTS: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001). CONCLUSIONS: Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

Tobacco Price Increase and Successful Smoking Cessation for Two or More Years in Japan.

INTRODUCTION: Assessing long-term smoking cessation after tobacco price increases is more valuable than short-term cessation as smokers often relapse after temporary cessation. We investigated whether tobacco price increases were associated with long-term smoking cessation and whether the association differed according to demographic, socioeconomic, and behavioral factors, using a national longitudinal survey of middle-aged individual-level data from 10 waves, every November from 2005 to 2014. METHODS: Temporary and long-term at least 1 year (1y+) or 2 years (2y+) quitters were defined by smoking in any one wave and quitting in the subsequent two or three waves in a discrete-time design. November 2006 (after July 11% increase) and November 2010 (after October 37% increase) were used as proxy variables for price increases. Generalized estimating equation models adjusted for demographic, socioeconomic, and behavioral covariates, and analyses stratified by these covariates were performed to estimate the association between price increases and smoking cessation. RESULTS: Of 43 630 smokers aged 50-65, 7.7%, 5.6%, and 5.2% of smokers quit temporarily, for at least 1 year and at least 2 years, respectively. 2y+ quitters significantly increased in November 2005-November 2008 (adjusted odds ratio = 1.23, 95% confidence interval: 1.06-1.43) and November 2009-November 2012 (adjusted odds ratio = 1.85, 95% confidence interval = 1.57-2.16). In stratified analyses, higher prices were associated with 2y+ quitters in all subgroups with some exceptions, including participants who smoked 21-30 cigarettes per day and those aged 60-65. CONCLUSIONS: Increasing tobacco prices may be effective in promoting long-term smoking cessation in various subgroups among middle-aged Japanese adults. IMPLICATIONS: Few longitudinal studies have examined the effect of a tobacco price increase on long-term smoking cessation. In a national longitudinal survey of middle-aged Japanese from 10 waves, the 37% tobacco price increase was found to be a trigger for successful smoking cessation for two or more years. Price increases were significantly associated with 2y+ smoking cessation in most demographic, behavioral, and socioeconomic subgroups. Results indicate that higher tobacco prices may be effective for long-term smoking cessation in almost all subgroups. Raising tobacco taxes and prices may be one of the most effective strategies for promoting long-term smoking cessation.

Comparative Safety of Smoking Cessation Pharmacotherapies During a Government-Sponsored Reimbursement Program.

INTRODUCTION: The British Columbia Ministry of Health launched a Smoking Cessation Program on September 30, 2011, providing financial coverage for smoking cessation pharmacotherapies. Although pharmacotherapies have been shown to have a moderate short-term benefit as a quitting aid, substantial cardiovascular and neuropsychiatric safety concerns have been identified in adverse-reporting databases, leading to prescription label warnings by Health Canada and the U.S. Food and Drug Administration. However, recent studies indicate these warnings may be without merit. This study examined the comparative safety of medications commonly used to aid smoking cessation. AIMS AND METHODS: Population-based retrospective cohort study using B.C. administrative data to assess the relative safety between varenicline, bupropion, and nicotine replacement therapies (NRTs). The primary outcome was a composite of cardiovascular hospitalizations. Secondary outcomes included mortality, a composite of neuropsychiatric hospitalizations, and individual components of the primary outcome. Statistical analysis used propensity score-adjusted log-binomial regression models. A sensitivity analysis excluded patients with a history of cardiovascular disease. RESULTS: The study included 116 442 participants. Compared with NRT, varenicline was associated with a 10% 1-year relative risk decrease of cardiovascular hospitalization (adjusted risk ratio [RR] = 0.90, 95% confidence interval (CI): 0.82 to 1.00), a 20% 1-year relative risk decrease of neuropsychiatric hospitalization (RR: 0.80, CI: 0.7 to 0.89), and a 19% 1-year relative risk decrease of mortality (RR: 0.81, CI: 0.71 to 0.93). We found no significant association between NRT and bupropion for cardiovascular hospitalizations, neuropsychiatric hospitalizations, or mortality. CONCLUSIONS: Compared with NRT, varenicline is associated with fewer serious adverse events and bupropion the same number of serious adverse events. IMPLICATIONS: This study addresses the need for comparative safety evidence in a real-world setting of varenicline and bupropion against an active comparator. Compared with NRT, varenicline was associated with a decreased risk of mortality, serious cardiovascular events, and neuropsychiatric events during the treatment, or shortly after the treatment, in the general population of adults seeking pharmacotherapy to aid smoking cessation. These results provide support for the removal of the varenicline boxed warning for neuropsychiatric events and add substantively to the cardiovascular safety findings of previous observational studies and randomized clinical trials.

Factors Associated With Progression to Surgical Intervention for Lumbar Disc Herniation in the Military Health System.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine surgery-free survival of patients receiving conservative management of lumbar disc herniation (LDH) in the military healthcare system (MHS) and risk factors for surgical intervention. SUMMARY OF BACKGROUND DATA: Radiculopathy from LDH is a major cause of morbidity and cost. METHODS: The Military Data Repository was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility (MTF) was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a MTF or in the civilian sector. The Military Data Repository was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention. RESULTS: A total of 84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a MTF during the 8-year study period. A total of 10,532 (12.4%) MHS beneficiaries, including 7650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow-up time of the cohort was 5.2 (interquartile range 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex, and history of tobacco use) and facility-level characteristics (hospital vs. clinic and surgical care vs. primary care clinic) were independently associated with higher risk of surgical intervention. CONCLUSION: LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.Level of Evidence: 4.

Economic Costs of Diseases and Deaths Attributable to Tobacco Use in India, 2017-2018.

INTRODUCTION: About 28.6% of Indian adults use tobacco. This study estimates the economic burden of deaths and diseases attributable to smoking and smokeless tobacco (SLT) use for persons aged ≥35 years. METHODS: The National Sample Survey data on healthcare expenditures, the Global Adult Tobacco Survey data on tobacco use prevalence, and relative risks of all-cause mortality from tobacco use were used to estimate the economic burden of diseases and deaths attributable to tobacco use in India, using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical and nonmedical expenditures; (2) indirect morbidity costs; and (3) indirect mortality costs of premature deaths. RESULTS: Total economic costs attributable to tobacco use from all diseases and deaths in India in the year 2017-2018 for persons 35 years or older amount to INR 1773.4 billion (US $27.5 billion), of which 22% is direct and 78% is indirect cost. Men bear 91% of the total costs. Smoking contributed 74% and SLT use contributed 26% of the costs. CONCLUSIONS: The economic costs of tobacco use amount to approximately 1.04% of India's gross domestic product (GDP), while the excise tax revenue from tobacco in the previous year was only 12.2% of its economic costs. The direct medical costs alone amount to 5.3% of total health expenditure. The enormous costs imposed on the nation's health care system due to tobacco use could potentially stress the public health care system and strain the economy and it warrants massive scaling up of tobacco control efforts in India. IMPLICATIONS: The study finds that the economic burden from tobacco constitutes more than 1% of India's GDP, and the direct health expenditures on treating tobacco-related diseases alone accounts for 5.3% of the total private and public health expenditures in India in a year. It shows that, for every INR 100 that is received as excise taxes from tobacco products, INR 816 of costs is imposed on society through its consumption. It establishes that tobacco consumption is a major resource drain on the national exchequer, and its effective regulation through comprehensive fiscal and non-fiscal policies is highly warranted.