"Deaths of despair" over the business cycle: New estimates from a shift-share instrumental variables approach.

This study presents new evidence of the effects of short-term economic fluctuations on suicide, fatal drug overdose, and alcohol-related mortality among working-age adults in the United States from 2003-2017. Using a shift-share instrumental variables approach, I find that a one percentage point increase in the aggregate employment rate decreases current-year non-drug suicides by 1.7 percent. These protective effects are concentrated among working-age men and likely reflect a combination of individual labor market experiences as well as the indirect effects of local economic growth. I find no consistent evidence that short-term business cycle changes affect drug or alcohol-related mortality. While the estimated protective effects are small relative to secular increases in suicide in recent decades, these findings are suggestive of important, short-term economic factors affecting specific causes of death and should be considered alongside the longer-term and multifaceted social, economic, and cultural determinants of America's "despair" epidemic.

Incentive programmes for smoking cessation: cluster randomized trial in workplaces in Thailand.

OBJECTIVE: To compare several monetary incentive programmes for promoting smoking abstinence among employees who smoke at workplaces in a middle income country. DESIGN: Parallel group, open label, assessor blinded, cluster randomized controlled trial. SETTING: Large industrial workplaces in metropolitan Bangkok, Thailand. PARTICIPANTS: Employees who smoked cigarettes and planned to quit within six months recruited from 101 worksite clusters (84 different companies). INTERVENTIONS: Worksites were digitally cluster randomized by an independent investigator to usual care or usual care plus one of eight types of incentive programmes. Usual care consisted of one time group counseling and cessation support through a 28 day text messaging programme. The incentive programmes depended on abstinence at three months and varied on three intervention components: refundable deposits, assignment to a teammate, and bonus size ($20 (£15; €17) or $40). MAIN OUTCOME MEASURES: The primary outcome was biochemically verified seven day point prevalence smoking abstinence at 12 months. Secondary outcomes were programme acceptance at enrollment and smoking abstinence at three months (end of intervention) and at six months. All randomized participants who had complete baseline information were included in intention-to-treat analyses; participants with missing outcomes were coded as continuing smokers. RESULTS: Between April 2015 and August 2016, the trial enrolled 4190 participants. Eighteen were omitted because of missing baseline covariates and death before the primary endpoint, therefore 4172 participants were included in the intention-to-treat analyses. Programme acceptance was relatively high across all groups: 58.7% (2451/4172) overall and 61.3% (271/442) in the usual care group. Abstinence rates at 12 months did not differ among deposit programmes (336/2253, 14.9%) and non-deposit programmes (280/1919, 14.6%; adjusted difference 0.8 points, 95% confidence interval -2.7 to 4.3, P=0.65), but were somewhat lower for team based programmes (176/1348, 13.1%) than individual based programmes (440/2824, 15.6%; -3.2 points, -6.6 to -0.2, P=0.07), and higher for $40 bonus programmes (322/1954, 16.5%) than programmes with no bonus (148/1198, 12.4%; 5.9 points, 2.1 to 9.7, P=0.002). The $40 individual bonus was the most efficacious randomization group at all endpoints. Intervention components did not strongly interact with each other. CONCLUSIONS: Acceptance of monetary incentive programmes for promoting smoking abstinence was high across all groups. The $40 individual bonus programmes increased long term smoking abstinence compared with usual care, although several other incentive designs did not, such as team based programmes and deposit programmes. Incentive design in workplace wellness programmes might influence their effectiveness at reducing smoking rates in low resource settings. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02421224).

Can Labor Market Policies Reduce Deaths of Despair?

Do minimum wages and the earned income tax credit (EITC) mitigate rising "deaths of despair?" We leverage state variation in these policies over time to estimate event study and difference-in-differences models of deaths due to drug overdose, suicide, and alcohol-related causes. Our causal models find no significant effects on drug or alcohol-related mortality, but do find significant reductions in non-drug suicides. A 10 percent minimum wage increase reduces non-drug suicides among low-educated adults by 2.7 percent, and the comparable EITC figure is 3.0 percent. Placebo tests and event-study models support our causal research design. Increasing both policies by 10 percent would likely prevent a combined total of more than 700 suicides each year.

Peer effects in smoking cessation: An instrumental variables analysis of a worksite intervention in Thailand.

While smoking is widely acknowledged to be a social activity, limited evidence exists on the extent to which friends influence each other during worksite-based tobacco cessation interventions. Drawing on data from adult smokers (N = 1823) in a large, cluster randomized controlled trial in worksites in Thailand, this study examines the presence of social spillovers in the decision to abstain from smoking. We leverage a unique aspect of social network structure in these data-the existence of non-overlapping friendship networks-to address the challenge of isolating the effects of peers on smoking behavior from the confounding effects of endogenous friend selection and bidirectional peer influence. We find that individuals with workplace friends who have abstained from smoking during the trial are significantly more likely to abstain themselves. Instrumental variables estimates suggest that abstinence after 3 and 12 months increases 26 and 32 percentage points, respectively, for each additional workplace friend who abstains. These findings highlight the potential for workplace interventions to use existing social networks to magnify the effect of individual-level behavior change, particularly in low- and middle-income countries where tobacco cessation support tends to be limited.

Determinants of Childhood Zoonotic Enteric Infections in a Semirural Community of Quito, Ecuador.

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Animal Husbandry Practices and Perceptions of Zoonotic Infectious Disease Risks Among Livestock Keepers in a Rural Parish of Quito, Ecuador.

Small-scale livestock production plays an essential role as a source of income and nutrition for households in low- and middle-income countries, yet these practices can also increase risk of zoonotic infectious diseases, especially among young children. To mitigate this risk, there is a need to better understand how livestock producers perceive and manage risks of disease transmission. Twenty semistructured, in-depth interviews were conducted with small-scale livestock producers in a semirural parish of Quito, Ecuador. Interviews explored livestock-raising practices, including animal health-care practices and use of antimicrobials, family members' interactions with livestock and other animals, and perceptions of health risk associated with these practices and activities. Interviews were analyzed for common themes. Awareness of zoonotic disease transmission was widespread, yet few study participants considered raising livestock a significant health risk for themselves or their families. Several study households reported handling and consuming meat or poultry from sick or dead animals and using animal waste as a fertilizer on their crops. Households typically diagnosed and treated their sick animals, occasionally seeking treatment advice from employees of local animal feed stores where medications, including antimicrobials, are available over the counter. Despite a basic understanding of zoonotic disease risk, this study identified several factors, such as the handling and consumption of sick and dead animals and purchasing medications for sick animals over the counter, that potentially increase the risk of zoonotic disease transmission as well as the development and spread of antimicrobial resistance.