Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims.

BACKGROUND: Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine. METHODS: In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression. RESULTS: Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01-1.06]) and PCPs (aHR = 1.07[1.05-1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20-1.29] and aHR = 1.39[1.34-1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry). CONCLUSION: Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.

Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims.

Background: As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. Methods: This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. Results: Buprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82-0.83]) and psychotic disorders (aRR = 0.95[0.94-0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05-1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17-1.24]) and anxiety disorders (aHR = 1.12[1.09-1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. Conclusions: We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.

Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA.

BACKGROUND: Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples. OBJECTIVE: To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment. DESIGN: Retrospective cohort study. SUBJECTS: Reproductive-age (18-45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016). MAIN MEASURES: Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression. RESULTS: Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees. CONCLUSIONS: Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.

Benzodiazepine, Z-drug, and sleep medication prescriptions in male and female people with opioid use disorder on buprenorphine and comorbid insomnia: an analysis of multistate insurance claims.

STUDY OBJECTIVES: In adult populations, women are more likely than men to be prescribed benzodiazepines. However, such disparities have not been investigated in people with opioid use disorder (OUD) and insomnia receiving buprenorphine, a population with particularly high sedative/hypnotic receipt. This retrospective cohort study used administrative claims data from Merative MarketScan Commercial and MultiState Medicaid Databases (2006-2016) to investigate sex differences in the receipt of insomnia medication prescriptions among patients in OUD treatment with buprenorphine. METHODS: We included people aged 12-64 years with diagnoses of insomnia and OUD-initiating buprenorphine during the study timeframe. The predictor variable was sex (female versus male). The primary outcome was receipt of insomnia medication prescription within 60 days of buprenorphine start, encompassing benzodiazepines, Z-drugs, or non-sedative/hypnotic insomnia medications (e.g. hydroxyzine, trazodone, and mirtazapine). Associations between sex and benzodiazepine, Z-drug, and other insomnia medication prescription receipt were estimated using Poisson regression models. RESULTS: Our sample included 9510 individuals (female n = 4637; male n = 4873) initiating buprenorphine for OUD who also had insomnia, of whom 6569 (69.1%) received benzodiazepines, 3891 (40.9%) Z-drugs, and 8441 (88.8%) non-sedative/hypnotic medications. Poisson regression models, adjusting for sex differences in psychiatric comorbidities, found female sex to be associated with a slightly increased likelihood of prescription receipt: benzodiazepines (risk ratio [RR], RR = 1.17 [1.11-1.23]), Z-drugs (RR = 1.26 [1.18-1.34]), and non-sedative/hypnotic insomnia medication (RR = 1.07, [1.02-1.12]). CONCLUSIONS: Sleep medications are commonly being prescribed to individuals with insomnia in OUD treatment with buprenorphine, with sex-based disparities indicating a higher prescribing impact among female than male OUD treatment patients.

Association of Racial Disparity of Cannabis Possession Arrests Among Adults and Youths With Statewide Cannabis Decriminalization and Legalization.

Importance: Despite calls for cannabis decriminalization and legalization, research investigating the association of policy with arrest rates and racial disparities is scarce. Objectives: To examine racial differences in cannabis arrest rates among adults and youths after statewide decriminalization, legalization, and no policy changes. Design Setting and Participants: This case-control study used race-based arrest data from the Uniform Crime Reporting Program and Surveillance, Epidemiology, and End Results county-level population data from January 2000 through December 2019. Data were analyzed in July 2021. Event-study analyses based on the arrest rates from 43 US states were conducted to compare preimplementation and postimplementation differences in arrest rates for states with decriminalization, legalization, and no policy changes. Exposures: Nine states implemented legalization, 8 implemented decriminalization, and 26 had no policy change. Main Outcomes and Measures: Outcome measures were cannabis arrest rates for Black and White adults and youths per year and by state, while controlling for several covariates. Results: Rates were reported per 100 000. When comparing absolute differences in arrests from January to December 2008 (before policy changes) to January to December 2019, legalization was associated with 561 and 195 fewer arrests and decriminalization with 448.6 and 117.1 fewer arrests for Black and White adults, respectively. States without a policy change saw reductions of 47.5 and 33.0 arrests for Black and White adults, respectively. Among youth, legalization was associated with 131.1 and 131.2 fewer arrests and decriminalization with 156.1 and 124.7 fewer arrests for Black and White youths, respectively. Among states without a policy change, arrests reduced by 35 and 52.4 for Black and White youths, respectively. Plotted trends of the arrest ratios from January 2000 through December 2019 suggests racial disparities remained over time. Event-study analyses suggest that decriminalization was associated with an arrest rate reduction for Black and White adults and youths. The timing of reductions suggests differential policy effects. Arrest disparities increased in states that did not have a cannabis policy change. Conclusions and Relevance: In this case-control study of states with and without cannabis decriminalization and legalization policies, increased arrest rate disparities in states without either policy highlight the need for targeted interventions to address racial injustice.

Age disparities in six-month treatment retention for opioid use disorder.

BACKGROUND AND AIMS: Adolescents with opioid use disorder (OUD) are an understudied and vulnerable population. We examined the association between age and six-month treatment retention, and whether any such association was moderated by medication treatment. METHODS: In this retrospective cohort study, we used an insurance database with OUD treatment claims from 2006-2016. We examined 261,356 OUD treatment episodes in three age groups: adolescents (ages 12-17), young adults (18-25) and older adults (26-64). We used logistic regression to estimate prevalence of six-month retention before and after stratification by treatment type (buprenorphine, naltrexone, or psychosocial only). Insurance differences (commercial vs Medicaid) in medication treatment prevalence were also assessed. RESULTS: Adolescents were less likely to be retained compared to adults (17.6 %; 95 % CI 16.5-18.7 % for adolescents; 25.1 %; 95 % CI 24.7-25.4 % for young adults; 33.3 %; 95 % CI 33.0-33.5 % for older adults). This disparity was reduced after adjusting for treatment type. For all ages, buprenorphine was more strongly associated with retention than naltrexone or psychosocial treatment. Adolescents who received buprenorphine were more than four times as likely to be retained in treatment (44.8 %; 95 % CI 40.6-49.0) compared to those who received psychosocial services (9.7 %; 95 % CI 8.8-10.8). Persons with commercial insurance were more likely to receive medication than those with Medicaid (73 % vs 36 %, (χ2 = 38,042.6, p < .001). CONCLUSIONS: Age disparities in six-month treatment retention are strongly related to age disparities in medication treatment. Results point to need for improved implementation of medication treatment for persons with OUD, regardless of age or insurance status.

Increases in Secondhand Smoke After Going Smoke-Free: An Assessment of the Impact of a Mandated Smoke-Free Housing Policy.

OBJECTIVE: The 12-month impact of federally mandated smoke-free housing (SFH) policy adoption (July 2018) was assessed using two markers of ambient secondhand smoke (SHS): airborne nicotine and particulate matter at the 2.5-micrometer threshold (PM2.5). METHODS: We measured markers of SHS in Norfolk, VA from December 2017 to December 2018 in six federally subsidized multi-unit public housing buildings. Multi-level regression was used to model the following comparisons: (1) the month immediately before SFH implementation versus the month immediately after, and (2) December 2017 versus December 2018. RESULTS: There was a 27% reduction in indoor PM2.5 and a 32% reduction in airborne nicotine in the first month after SFH adoption, compared to the month prior to adoption. However, there was a 33% increase in PM2.5 and a 25% increase in airborne nicotine after 12 months. CONCLUSIONS: US Department of Housing and Urban Development (HUD)-mandated SFH can reduce SHS in multi-unit housing. However, SFH could also plausibly increase indoor smoking. Policy approaches adopted by individual properties or housing authorities-for example, property-wide bans versus allowing designated smoking areas-could be driving this potential unintended consequence. IMPLICATIONS: Successful implementation of SFH by public housing authorities in response to the HUD rule requires ongoing attention to implementation strategies. In this sense, SFH likely differs from other policies that might be seen as less intrusive. Long-term success of SFH will depend on careful policy implementation, including plans to educate and support housing authority staff, inform and engage residents, and build effective partnerships with community agencies.

Changes in alcohol and cigarette consumption in response to medical and recreational cannabis legalization: Evidence from U.S. state tax receipt data.

BACKGROUND: Whether medical or recreational cannabis legalization impacts alcohol or cigarette consumption is a key question as cannabis policy evolves, given the adverse health effects of these substances. Relatively little research has examined this question. The objective of this study was to examine whether medical or recreational cannabis legalization was associated with any change in state-level per capita alcohol or cigarette consumption. METHODS: Dependent variables included per capita consumption of alcohol and cigarettes from all 50 U.S. states, estimated from state tax receipts and maintained by the Centers for Disease Control and National Institute for Alcohol Abuse and Alcoholism, respectively. Independent variables included indicators for medical and recreational legalization policies. Three different types of indicators were separately used to model medical cannabis policies. Indicators for the primary model were based on the presence of active medical cannabis dispensaries. Secondary models used indicators based on either the presence of a more liberal medical cannabis policy ("non-medicalized") or the presence of any medical cannabis policy. Difference-in-difference regression models were applied to estimate associations for each type of policy. RESULTS: Primary models found no statistically significant associations between medical or recreational cannabis legalization policies and either alcohol or cigarette sales per capita. In a secondary model, both medical and recreational policies were associated with significantly decreased per capita cigarette sales compared to states with no medical cannabis policy. However, post hoc analyses demonstrated that these reductions were apparent at least two years prior to policy adoption, indicating that they likely result from other time-varying characteristics of legalization states, rather than cannabis policy. CONCLUSION: We found no evidence of a causal association between medical or recreational cannabis legalization and changes in either alcohol or cigarette sales per capita.

A comparison of buprenorphine and psychosocial treatment outcomes in psychosocial and medical settings.

BACKGROUND: Facing an epidemic of opioid-related mortality, many government health departments, insurers, and treatment providers have attempted to expand patient access to buprenorphine in psychosocial substance use disorder (SUD) programs and medical settings. METHODS: With Missouri Medicaid data from 2008 to 2015, we used Cox proportional hazard models to estimate the relative hazards for treatment attrition and SUD-related emergency department (ED) visits or hospitalizations associated with buprenorphine in psychosocial SUD programs and medical settings. We also tested the association of buprenorphine with hours of psychosocial treatment during the first 30 days of psychosocial SUD treatment. The analytic sample included claims from 7606 individuals with an OUD diagnosis. RESULTS: Compared to psychosocial treatment without buprenorphine (PSY), the addition of buprenorphine (PSY-B) was associated with a significantly reduced hazard for treatment attrition (adjusted hazard ratio: 0.67, 95% CI: 0.62-0.71). Among buprenorphine episodes, office-based (B-OBOT), outpatient hospital (B-OPH), and no documented setting (B-PHA) were associated with reduced hazards for treatment attrition when compared to the psychosocial SUD setting (B-PSY) (adjusted hazard ratios: 0.27, 95% CI: 0.24-0.31; 0.46, 95% CI: 0.39-0.54; 0.70, 95% CI: 0.61-0.81). Compared to B-PSY, B-OBOT and B-PHA were associated with significantly reduced hazards for a SUD-related ED visits or hospitalization (adjusted hazard ratios: 0.59, 95% CI: 0.41-0.85; 0.53, 95% CI: 0.36-0.78). There was no significant difference between B-PSY and B-OPH or B-PSY and PSY in hazard for an SUD-related ED visit or hospitalization. CONCLUSIONS: Our findings support the conclusion that adding buprenorphine to Medicaid-covered psychosocial SUD treatment reduces patient attrition and SUD-related ED visits or hospitalizations but that buprenorphine treatment in office-based medical settings is even more effective in reducing these negative outcomes. Policy-makers should consider ways to expand buprenorphine access in all settings, but particularly in office-based medical settings. Buprenorphine treatment in an unbilled setting was associated with an increased hazard for patient attrition when compared to treatment in billed medical settings, indicating the importance of Medicaid-covered provider visits for patient retention.

Trends in Prescribed Central Nervous System Depressant Medications Among Adults Who Regularly Consume Alcohol: United States 1999 to 2014.

BACKGROUND: Although the risks of using central nervous system depressant (CNS-D) medications with alcohol are well documented, little is known about trends in prescribed use of these medications among individuals who regularly consume alcohol (i.e., trends in "concurrent use"). We examined changes in the prevalence of prescribed CNS-D medications among individuals who drank alcohol on 52 or more occasions in the past year ("regular drinking"). CNS-D medications included sedative-hypnotics (subclassified as anxiolytics or sleep medications) and opioids. METHODS: We used 8 cross-sectional cycles of the National Health and Nutrition Examination Survey (1999-2000 to 2013-2014) from participants aged 20 and older (n = 37,709). We used log-binomial regression to examine (i) prevalence trends of prescribed CNS-D medication use, (ii) trend differences by drinking status, and (iii) correlates of CNS-D medication use. RESULTS: Among those who drink regularly, the relative annual increase in prevalence of sedative-hypnotic use was 5.3% (95% CI: 2.7 to 7.9): Anxiolytic and sleep medication use increased annually by 3.7% (95% CI: 0.8 to 6.7) and 11.2% (95% CI: 6.5 to 16.0), respectively. Opioid use trends among those who drink regularly were not statistically significant but were nonlinear. Differences in CNS-D medication trends between those who drink regularly and those who drink infrequently/abstain were not statistically significant. Those who drink regularly were less likely than those who drink infrequently/abstain to use opioids (adjusted relative risk [ARR]: 0.69, 95% CI: 0.60 to 0.78) and anxiolytics (ARR: 0.71, 95% CI: 0.61 to 0.81), but not sleep medications (ARR: 1.04, 95% CI: 0.80 to 1.35). Those aged 40 and older were 2 to 5 times as likely as those aged 20 to 29 to use sedative-hypnotics. CONCLUSIONS: Among those who drink regularly, the prevalence of prescribed sedative-hypnotic use increased and prescribed opioid use remained common. These trends indicate that a substantial portion of the population is at risk of alcohol-related adverse drug reactions-particularly those aged 40 and older.

Daily Drinking Is Associated with Increased Mortality.

BACKGROUND: There is evidence that low-level alcohol use, drinking 1 to 2 drinks on occasion, is protective for cardiovascular disease, but increases the risk of cancer. Synthesizing the overall impact of low-level alcohol use on health is therefore complex. The objective of this paper was to examine the association between frequency of low-level drinking and mortality. METHODS: Two data sets with self-reported alcohol use and mortality follow-up were analyzed: 340,668 individuals from the National Health Interview Survey (NHIS) and 93,653 individuals from the Veterans Health Administration (VA) outpatient medical records. Survival analyses were conducted to evaluate the association between low-level drinking frequency and mortality. RESULTS: The minimum risk drinking frequency among those who drink 1 to 2 drinks per occasion was found to be 3.2 times weekly in the NHIS data, based on a continuous measure of drinking frequency, and 2 to 3 times weekly in the VA data. Relative to these individuals with minimum risk, individuals who drink 7 times weekly had an adjusted hazard ratio (HR) of all-cause mortality of 1.23 (p < 0.0001) in the NHIS data, and individuals who drink 4 to 7 times weekly in the VA data also had an adjusted HR of 1.23 (p = 0.01). Secondary analyses in the NHIS data showed that the minimum risk was drinking 4 times weekly for cardiovascular mortality, and drinking monthly or less for cancer mortality. The associations were consistent in stratified analyses of men, women, and never smokers. CONCLUSIONS: The minimum risk of low-level drinking frequency for all-cause mortality appears to be approximately 3 occasions weekly. The robustness of this finding is highlighted in 2 distinctly different data sets: a large epidemiological data set and a data set of veterans sampled from an outpatient clinic. Daily drinking, even at low levels, is detrimental to one's health.

A reexamination of medical marijuana policies in relation to suicide risk.

OBJECTIVES: Previous research has suggested that medical marijuana policies lead to reductions in suicide rates. In this study, we further investigate the association between these policies and within-state changes in suicide risk. METHODS: Data on suicide deaths (n=662,993) from the National Vital Statistics System Multiple Cause of Death files were combined with living population data. Fixed-effects regression methods were employed to control for state differences in suicide rates and national and state secular trends. Analyses extended prior research that suggested a protective effect of medical marijuana policies by incorporating newer data and additional covariates. RESULTS: After adjustment for race/ethnicity, tobacco control policies, and other covariates, we found no association between medical marijuana policy and suicide risk in the population ages 15 and older (OR=1.000; 95% CI: 0.956, 1.045; p=0.98), among men overall (OR=0.996; 95% CI: 0.951, 1.043; p=0.87) or for any other age-by-sex groups. CONCLUSION: We find no statistically significant association between medical marijuana policy and suicide risk. These results contradict prior analyses which did not control for race/ethnicity and certain state characteristics such as tobacco control policies. Failure to control for these factors in future analyses would likely bias estimates of the associations between medical marijuana policy and health outcomes.

Effects of state cigarette excise taxes and smoke-free air policies on state per capita alcohol consumption in the United States, 1980 to 2009.

BACKGROUND: Increasing state cigarette excise taxes and strengthening smoke-free air (SFA) laws are known to reduce smoking prevalence. Some studies suggest that such policies may also reduce alcohol use, but results for cigarette taxes have been mixed, and associations with smoke-free air policies have been limited to some demographic subgroups. To shed further light on the potential secondary effects of tobacco control policy, we examined whether increases in cigarette taxes and strengthening of SFA laws were associated with reductions of per capita alcohol consumption and whether any reductions were specific to certain beverage types. METHODS: State per capita alcohol consumption from 1980 to 2009 was modeled as a function of state price per pack of cigarettes and SFA policy scores while controlling for secular trends and salient state covariates. Both policy measures also accounted for local policies. Total alcohol, beer, wine, and spirits consumption per capita were modeled separately. For each type of beverage, we used a nested models approach to determine whether the 2 policies together were associated with reduced consumption. RESULTS: For total alcohol consumption, and for beer or spirits (but not wine), one or both tobacco policies were associated with reductions in consumption. A 1% increase in cigarette price per pack was associated with a 0.083% decrease in per capita total alcohol consumption (95% confidence interval [CI] 0.0002 to 0.166, p = 0.0495), and a 1-point increase in SFA policy score, measured on a 6-point scale, was associated with a 1.1% decrease in per capita total alcohol consumption (95% CI 0.4 to 1.7, p = 0.001; p < 0.001 for the hypothesis that the 2 policies are jointly associated with reduced alcohol consumption). CONCLUSIONS: The public health benefits of increasing cigarette taxes and smoke-free policies may go beyond the reduction of smoking and extend to alcohol consumption, specifically beer and spirits.

Probing the smoking-suicide association: do smoking policy interventions affect suicide risk?

INTRODUCTION: Smokers exhibit elevated risk for suicide, but it is unknown whether smoking interventions reduce suicide risk. We examined whether state-level policy interventions-increases in cigarette excise taxes and strengthening of smoke-free air laws-corresponded to a reduction in suicide risk during the 1990s and the early 2000s. We also examined whether the magnitude of such reductions correlated with individuals' predicted probability of smoking, which would be expected if the associations stemmed from changes in smoking behavior. METHODS: We paired individual-level data on suicide deaths from the U.S. Multiple Cause of Death files, years 1990-2004, with living population data from the same period. These were linked with state data on cigarette excise taxes and smoke-free air policies. Utilizing a quasiexperimental analytical approach, we estimated the association between changes in policy and suicide risk. To examine whether associations correlated with individuals' probability of smoking, we used external survey data to derive a predicted probability of smoking function from demographic variables, which was then used to stratify the population by predicted smoking prevalence. RESULTS: Cigarette excise taxes, smoke-free air policies, and an index combining the two policies all exhibited protective associations with suicide. The associations were strongest in segments of the population where predicted smoking prevalence was the highest and weaker in segments of the population where predicted smoking prevalence was the lowest, suggesting that the protective associations were related to changes in smoking behavior. CONCLUSION: These results provide support for the proposition that population interventions for smoking could reduce risk for suicide.

Differential effects of cigarette price changes on adult smoking behaviours.

BACKGROUND: Raising cigarette prices through taxation is an important policy approach to reduce smoking. Yet, cigarette price increases may not be equally effective in all subpopulations of smokers. PURPOSE: To examine differing effects of state cigarette price changes with individual changes in smoking among smokers of different intensity levels. METHODS: Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults originally interviewed in 2001-2002 (Wave 1) and re-interviewed in 2004-2005 (Wave 2): 34 653 were re-interviewed in Wave 2, and 7068 smokers defined at Wave 1 were included in our study. Mixed effects linear regression models were used to assess whether the effects of changes in state cigarette prices on changes in daily smoking behaviour differed by level of daily smoking. RESULTS: In the multivariable model, there was a significant interaction between change in price per pack of cigarettes from Wave 1 to Wave 2 and the number of cigarettes smoked per day (p=0.044). The more cigarettes smoked per day at baseline, the more responsive the smokers were to increases in price per pack of cigarettes (ie, number of cigarettes smoked per day was reduced in response to price increases). CONCLUSIONS: Our findings that heavier smokers successfully and substantially reduced their cigarette smoking behaviours in response to state cigarette price increases provide fresh insight to the evidence on the effectiveness of higher cigarette prices in reducing smoking.

The persistent effects of minimum legal drinking age laws on drinking patterns later in life.

BACKGROUND: Exposure to permissive minimum legal drinking age (MLDA) laws not only affects young adults in the short term, but also later in life; for example, individuals who could legally purchase alcohol before the age of 21 are more likely to suffer from drinking problems as older adults, long after the laws had been changed. However, it is not known how permissive MLDA exposure affects specific drinking behavior. This present study uses changes in MLDA laws during the 1970s and 1980s as a natural experiment to investigate the potential impact of permissive MLDA exposure on average alcohol consumption, frequency of drinking, and patterns of binging and more moderate, nonheavy drinking. METHODS: Policy exposure data were paired with alcohol use data from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year drinkers born between 1949 and 1972 (n = 24,088) were included. Average daily intake, overall drinking frequency, and frequency of both binge episodes (5+ drinks) and days without a binge episode (nonheavy drinking) for the previous year at the time of interview were tracked for each respondent. RESULTS: Exposure to permissive MLDAs was associated with higher odds to report frequent binging and lower odds to report any moderate drinking; these associations were largely driven by men and those who did not attend college. Overall drinking frequency and average alcohol consumption were not affected by MLDA exposure. CONCLUSIONS: The ability to legally purchase alcohol before the age of 21 does not seem to increase overall drinking frequency, but our findings suggest that it is associated with certain types of problematic drinking behaviors that persist into later adulthood: more frequent binge episodes and less frequent nonheavy drinking. We also propose that policymakers and critics should not focus on college drinking when evaluating the effectiveness of MLDAs.

The legacy of minimum legal drinking age law changes: long-term effects on suicide and homicide deaths among women.

BACKGROUND: Prior to the establishment of the uniform drinking age of 21 in the United States, many states permitted legal purchase of alcohol at younger ages. Lower drinking ages were associated with several adverse outcomes, including elevated rates of suicide and homicide among youth. The objective of this study is to examine whether individuals who were legally permitted to drink prior to age 21 remained at elevated risk in adulthood. METHODS: Analysis of data from the U.S. Multiple Cause of Death files, 1990 to 2004, combined with data on the living population from the U.S. Census and American Community Survey. The assembled data contained records on over 200,000 suicides and 130,000 homicides for individuals born between 1949 and 1972, the years during which the drinking age was in flux. Logistic regression models were used to evaluate whether adults who were legally permitted to drink prior to age 21 were at elevated risk for death by these causes. A quasi-experimental analytical approach was employed, which incorporated state and birth-year fixed effects to account for unobserved covariates associated with policy exposure. RESULTS: In the population as a whole, we found no association between minimum drinking age and homicide or suicide. However, significant policy-by-sex interactions were observed for both outcomes, such that women exposed to permissive drinking age laws were at higher risk for both suicide (OR = 1.12, 95% CI: 1.05, 1.18, p = 0.0003) and homicide (OR = 1.15, 95% CI: 1.04, 1.25, p = 0.0028). Effect sizes were stronger for the portion of the cohort born after 1960, whereas no significant effects were observed for women born prior to 1960. CONCLUSIONS: Lower drinking ages may result in persistent elevated risk for suicide and homicide among women born after 1960. The national drinking age of 21 may be preventing about 600 suicides and 600 homicides annually.

Personality as a mediator of demographic risk factors for suicide attempts in a community sample.

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.