Smoking-Attributable Health Care Expenditures for US Adults With Chronic Lower Respiratory Disease.

Importance: Cigarette smoking is a primary risk factor for chronic lower respiratory disease (CLRD) and is associated with worse symptoms among people with CLRD. It is important to evaluate the economic outcomes of smoking in this population. Objective: To estimate smoking prevalence and cigarette smoking-attributable health care expenditures (SAHEs) for adults with CLRD in the US. Design, Setting, and Participants: This cross-sectional study used data from the 2014-2018 and 2020 National Health Interview Surveys (NHIS) and the 2020 Medical Expenditure Panel Survey. The final study population, stratified by age 35 to 64 years and 65 years or older, was extracted from the 2014-2018 NHIS data. The data analysis was performed between February 1 and March 31, 2024. Exposures: Cigarette smoking, as classified into 4 categories: current smokers, former smokers who quit less than 15 years ago, former smokers who quit 15 or more years ago, and never smokers. Main Outcomes and Measures: Smoking-attributable health care expenditures were assessed using a prevalence-based annual cost approach. Econometric models for the association between cigarette smoking and health care utilization were estimated for 4 types of health care services: inpatient care, emergency department visits, physician visits, and home health visits. Results: In the 2014-2018 NHIS study sample of 13 017 adults, 7400 (weighted 62.4%) were aged 35 to 64 years, 5617 (weighted 37.6%) were 65 years or older, and 8239 (weighted 61.9%) were female. In 2020, among 11 211 222 adults aged 35 to 64 with CLRD, 3 508 504 (31.3%) were current smokers and 3 496 790 (31.2%) were former smokers. Total SAHEs in 2020 for this age group were $13.6 billion, averaging $2752 per current smoker and $1083 per former smoker. In 2020, 7 561 909 adults aged 65 years or older had CLRD, with 1 451 033 (19.2%) being current smokers and 4 104 904 (54.3%) being former smokers. Total SAHEs in 2020 for the older age group were $5.3 billion, averaging $1704 per current smoker and $682 per former smoker. In sum, SAHEs for adults with CLRD aged 35 years or older amounted to $18.9 billion in 2020. Conclusions and Relevance: In this cross-sectional study of adults with CLRD, cigarette smoking was associated with a substantial health care burden. The higher per-person SAHEs for current smokers compared with former smokers suggest potential cost savings of developing targeted smoking cessation interventions for this population.

Association between tobacco product use and respiratory health and asthma-related interference with activities among U.S. Adolescents.

Tobacco use adversely affects long-term respiratory health. We examined the relationship between sole and dual tobacco product use and both respiratory health and respiratory-related quality of life during adolescence in the U.S. Using adolescent data (baseline age 12-17) from Waves 4.5 (data collected from December 2017-December 2018) and 5 (data collected from December 2018-November 2019) of the Population Assessment of Tobacco and Health Study, we examined the associations between combustible (i.e., cigarette or cigar), vaped, and dual (i.e., both cigar/cigarette and e-cigarette) tobacco/nicotine use at baseline and two respiratory symptoms (all adolescents, n = 11,748) and new asthma diagnosis (adolescents with no baseline diagnosis, n = 9,422) at follow-up. Among adolescents with asthma (Wave 5, n = 2,421), we estimated the association between current tobacco use and the extent to which asthma interfered with daily activities. At follow-up, 12.3 % of adolescents reported past 12-month wheezing/whistling, 17.4 % reported past 12-month dry cough, and 1.9 % reported newly diagnosed asthma. Baseline current cigarette/cigar smoking was associated with subsequent wheezing/whistling and baseline report of another tobacco product use pattern was associated with subsequent asthma diagnosis. Among adolescents with asthma, 5.7 % reported it interfering with activities some of the time and 3.1 % reported interference most/all of the time in the past 30 days. Past 30-day sole cigarette/cigar smoking and dual use was positively associated with asthma-related interference with activities compared to never tobacco use and sole e-cigarette use. Combustible and dual tobacco use pose direct risk to respiratory health and indirect risk to quality of life through respiratory health.

The association of current exclusive e-cigarette use and dual use of e-cigarettes and cigarettes with psychological distress among U.S. adults.

This observational study examines the association of current e-cigarette use and dual use of e-cigarettes and cigarettes (dual use) with psychological distress among U.S. adults. We differentiate dual use based on the smoking frequency and compare the relationship between dual use and psychological distress to that of exclusive cigarette smoking with the same smoking frequency. Using data from the 2015-2018 National Health Interview Surveys, we analyzed adults aged 18+ (N = 55,780) who currently use e-cigarettes or/and cigarettes and have no history of using other tobacco products, and adults who never used any tobacco. Multinomial logistic regression models estimate the association of current e-cigarette use and dual use with psychological distress severity (no/mild, moderate, and severe).In the sample, 15.3% and 2.9% of adults experienced moderate and severe psychological distress. Compared to never tobacco users, current exclusive e-cigarette users and dual users who smoke daily had higher odds of moderate and severe psychological distress. Dual users who smoke nondaily had higher odds of moderate, but not severe psychological distress than never tobacco users. Compared to exclusive daily smokers, dual users with daily smoking had higher odds of moderate and severe psychological distress. Compared to exclusive nondaily smokers, dual users with nondaily smoking had higher odds of moderate but not severe psychological distress. Our findings suggest that exclusive e-cigarette use is associated with psychological distress severity. Dual use is associated with higher odds of psychological distress severity compared to never tobacco users and exclusive cigarette smoking, and this association differs by smoking frequency.

Association between e-cigarette use and food insecurity among low-income adults.

INTRODUCTION: Previous research quantifying the relationship between tobacco use and food insecurity has focused on cigarette smoking. E-cigarette use has become popular in recent years. Drawing on large, population-based survey data, this study augments the previous research, considering the association of e-cigarette use with food insecurity among low-income adults. METHODS: We analysed data from the California Health Interview Survey in 2014-2019. The study sample consisted of 25 948 respondents aged 18-64 who lived in low-income (<200% of the Federal Poverty Level) households. Multivariable logistic regression models were estimated to examine the associations of e-cigarette use as well as dual use of e-cigarettes and cigarettes with food insecurity. RESULTS: Of California low-income adults, 6.4% identified as current e-cigarette users (3.0% dual users of e-cigarettes and cigarettes, and 3.4% sole e-cigarette users) and 43.0% reported food insecurity. After controlling for confounding factors, food insecurity was significantly more likely to be reported among current e-cigarette users (adjusted OR (AOR)=1.67; 95% CI 1.25 to 2.23) compared with never e-cigarette users, and among dual users (AOR=2.21; 95% CI 1.63 to 3.00), current sole e-cigarette users (AOR=1.66; 95% CI 1.15 to 2.40), and current sole cigarette smokers (AOR=1.46; 95% CI 1.22 to 1.76) compared with never tobacco users. The odds of food insecurity among dual users were significantly greater than sole cigarette smokers but not statistically different from sole e-cigarette users. CONCLUSIONS: Using e-cigarette is an associated risk factor for food insecurity among low-income adults. Dual use of e-cigarettes and cigarettes has a significantly greater risk of food insecurity compared with smoking cigarettes alone.

Healthcare utilisation and expenditures attributable to current e-cigarette use among US adults.

AIMS: This study estimated annual healthcare expenditures attributable to current e-cigarette use among US adults, including current exclusive and dual/poly e-cigarette use. METHODS: Analysing the 2015-2018 National Health Interview Survey data, we estimated the impacts of e-cigarette use on healthcare utilisation among adults aged 18+ years. Healthcare utilisation outcomes were hospital nights, emergency room (ER) visits, doctor visits and home visits. Current e-cigarette use was categorised as exclusive and dual/poly e-cigarette use. The econometric model included two equations: health status as a function of e-cigarette use and other independent variables, and healthcare utilisation as a function of health status, e-cigarette use, and other independent variables. Using an 'excess utilisation' approach, we multiplied the e-cigarette-attributable fraction derived from the model by annual health expenditures to calculate healthcare expenditures attributable to current exclusive and dual/poly e-cigarette use, the sum of which were expenditures attributable to all current e-cigarette use. RESULTS: Current exclusive and dual/poly e-cigarette use, with 0.2% and 3.5% prevalence in 2015-2018, were associated with higher odds of reporting poor health status than never tobacco users. Poor health status was associated with higher odds of using the four healthcare services and a greater number of ER and doctor visits. Annual healthcare expenditures attributable to all current e-cigarette use was $15.1 billion ($2024 per user) in 2018, including $1.3 billion attributable to exclusive e-cigarette use ($1796 per user) and $13.8 billion attributable to dual/poly e-cigarette use ($2050 per user). CONCLUSION: Adult current e-cigarette use was associated with substantial excess healthcare utilisation and expenditures.

Cigarette Gifting Among Nonsmokers in China: Findings From the International Tobacco Control China Survey.

INTRODUCTION: Cigarette gifting is commonly practiced in China and has contributed to the social acceptability and high prevalence of cigarette smoking in the country. As a result, nonsmokers in China are particularly susceptible to smoking. While previous studies have examined cigarette gifting behaviors among smokers, little is known about cigarette gifting among nonsmokers. AIMS AND METHODS: This study aimed to examine the percentage and correlates of giving and receiving cigarettes as gifts among adult nonsmokers in China. We analyzed nonsmokers (N = 1813) aged ≥18 years using data from the International Tobacco Control China Wave 5 Survey. Descriptive statistics summarized the characteristics of those who gave and received cigarettes as gifts. Multivariable logistic regression models were used to identify factors associated with the two behaviors. RESULTS: Among nonsmokers, 9.9% reported giving cigarettes as gifts to family or friends in the last 6 months. A higher level of knowledge about smoking harms was associated with lower adjusted odds of gifting cigarettes. Nonsmokers aged 25-39 years, with middle income, positive attitude toward cigarette gifts, exposure to anti-smoking information, and exposure to smoking promotion, and those who reported receiving cigarettes as gifts from family or friends were more likely to give cigarettes as gifts. A total of 6.6% of nonsmokers reported receiving cigarettes as gifts in the last 6 months. High education, neutral or positive attitude toward cigarette gifts, exposure to anti-smoking information, exposure to smoking promotion, and having smoking friends were associated with receiving cigarettes as gifts. CONCLUSIONS: It is concerning that Chinese cultural norms that support cigarette gifting have extended to giving nonsmokers cigarettes as gifts. Effective anti-smoking messages are needed. Changing the norms around cigarette gifting and increasing knowledge about smoking harms should help reduce cigarette gifting among nonsmokers. IMPLICATIONS: Easy access to cigarettes received as gifts, along with the wide acceptance of smoking in China, places Chinese nonsmokers in a risky position. More educational campaigns targeting nonsmokers to proactively prevent them from smoking are called for. The ineffectiveness of existing anti-smoking information highlights the need for more effective anti-smoking messages. That attitude toward cigarette gifts is the strongest predictor of giving cigarettes as gifts suggests the need for interventions to reverse the positive attitude about cigarette gifting to decrease the popularity of this activity.

Receiving and giving electronic cigarettes as gifts in China: Findings from International Tobacco Control China Survey.

Cigarette gifting is pervasive in China. As the Chinese are increasingly aware of harm from smoking cigarettes, e-cigarettes, often promoted as less harmful alternatives to cigarettes, may be viewed as appropriate gifts. This study is the first using population-based survey data to examine receiving and giving e-cigarettes as gifts in China. We analyzed 9,274 adults from Wave 5 of the International Tobacco Control China Survey, which was completed in July 2015. We found that the prevalence of receiving e-cigarettes as gifts was 1.3% among all respondents and 5.3% among urban smokers; the prevalence of giving e-cigarettes as gifts was 0.5% among all respondents and 1.2% among urban smokers. These prevalence estimates were very low among nonsmokers and rural respondents. Further analysis on urban smokers (N = 3,312) found that those aged 40-54 and 55+, those with high education levels, heavy smokers, and those who perceived e-cigarettes as equally/more harmful than cigarettes were more likely to receive e-cigarette gifts; and those who ever used e-cigarettes were significantly more likely to both receive and give e-cigarette gifts. Urban smokers with positive attitude about cigarette gifting were also more likely to give e-cigarette gifts to others, but those aged 55+ were less likely to gift e-cigarettes. Findings of this study indicate that the Chinese may perceive e-cigarettes as appropriate gifts for smokers, especially heavy smokers. Precautions should be taken to prevent e-cigarettes from becoming a gift choice for nonsmokers. Health campaigns designed to combat the social acceptance of cigarette gifting may also help reduce e-cigarette gifting.

Smoking-Attributable Doctor Visits and Emergency Room Utilization and Costs by California's Lesbian, Gay, and Bisexual Community.

The lesbian, gay, and bisexual (LGB) community is known to smoke at greater rates than the general population, but there has been no study estimating the impact of cigarette smoking on healthcare utilization and costs in the LGB population. Using data from the 2005-2014 California Health Interview Surveys, we determine smoking-attributable healthcare utilization and costs among California's LGB-identified community. Our findings indicate that lesbian/bisexual women who smoke incur excess doctor visits and emergency room visits compared to their never smoking counterparts. No statistically significant differences were found for gay/bisexual men. Annual smoking-attributable costs were $58.3 million for the California LGB community (2019 dollars).

The Association of Cannabis Use and Cigarette Smoking with Psychological Distress Among Adults in California.

BACKGROUND: In November 2016, California voters passed the Adult Use of Marijuana Act making recreational cannabis sales legal to adults aged 21and older starting January 1st, 2018. This study aims to understand the relationship of cannabis use and cigarette smoking with serious psychological distress (SPD) in California in light of the legalization of recreational cannabis sales. METHODS: This cross-sectional study included 42,313 adult participants from the 2017 to 2018 California Health Interview Surveys. We used the Kessler-6 (K6) scale to measure psychological distress in the past 30 days. Multiple logistic regression models were used to examine the association between cannabis/cigarette use and SPD. RESULTS: Cannabis use was positively associated with SPD (AOR = 2.48, 95% CI = 1.57, 3.91), but this association was not significantly different before and after recreational cannabis sales legalization in California (AOR = 0.82, 95% CI = 0.72, 2.05). Cigarette smoking was also positively associated with SPD (AOR = 2.76, 95% CI = 2.05, 3.71). Compared to those who used neither cannabis nor cigarettes, sole cannabis users (AOR = 2.51, 95% CI = 1.75, 3.60), sole cigarette smokers (AOR = 3.23, 95% CI = 2.28, 4.60), and dual users of cannabis and cigarettes (AOR = 5.65, 95% CI = 4.04, 7.89) were more likely to report SPD. Dual users were also more likely to report SPD than sole cannabis users (AOR = 2.25; 95% CI = 1.48, 3.43) and sole cigarette smokers (AOR = 1.75; 95% CI = 1.18, 2.59). CONCLUSIONS: These findings provide evidence for the need to develop effective cessation intervention strategies targeting individuals with SPD to reduce their cannabis use and dual-use of cannabis and cigarettes.

Changes in e-cigarette use and subsequent cigarette smoking cessation in the USA: evidence from a prospective PATH study, 2013-2018.

AIMS: To examine the relationship between changes in electronic cigarette (e-cigarette) use and subsequent cigarette smoking cessation. METHODS: Using data from the Population Assessment of Tobacco and Health Study (wave 1-wave 4), we analysed a study cohort of 3014 current adult cigarette smokers at wave 1 who tried to quit during the past 12 months. We categorised changes in e-cigarette use from wave 1 to wave 2 as: daily initiation, non-daily initiation, increase to daily use, increase to non-daily use, stable daily use, stable non-daily use, decrease from daily use, quit non-daily use and non-use. We estimated multivariable logistic regressions on short-term (≥1 month and <12 months) cigarette smoking cessation at wave 3 and long-term (≥12 months) cigarette smoking cessation at wave 4. We conducted sensitivity analyses using alternative study cohorts. RESULTS: Among the study cohort, 2.4% initiated daily, 7.5% initiated non-daily, 1.0% increased to daily, 1.4% increased to non-daily, 1.5% maintained daily, 3.0% maintained non-daily, 2.4% decreased from daily and 3.8% quit non-daily e-cigarette use between waves 1 and 2; 7.9% and 6.9% reported short-term and long-term cigarette smoking cessation. 15.1% of short-term and 16.3% of long-term cigarette quitters used e-cigarettes. Compared with non-users, smokers who initiated daily, increased to daily or quit non-daily e-cigarette use between waves 1 and 2 had higher odds of short-term cigarette smoking cessation at wave 3. These results are robust to different study cohort specifications. CONCLUSION: The findings suggest a complex relationship between changes in e-cigarette use and subsequent cigarette smoking cessation.

The Association of California's Proposition 56 Tobacco Tax Increase With Smoking Behavior Across Racial and Ethnic Groups and by Income.

INTRODUCTION: On April 1, 2017, California Proposition 56 (Prop 56) was implemented, increasing the excise tax on cigarettes by $2/pack. This study compares the association of Prop 56 with smoking prevalence and smoking intensity across racial/ethnic groups, further examining distinctions across income subgroups within each racial/ethnic group. AIMS AND METHODS: The study used pooled cross-sectional data from the 2012-2018 California Behavioral Risk Factor Surveillance System. We examined two outcomes: current smoking prevalence and smoking intensity conditional on current smoking. A two-part econometric model was used to estimate the association of Prop 56 with smoking prevalence and intensity using multiple logistic regression and multiple linear regression, respectively. The two-part model was run separately for all adults (full sample) and each racial/ethnic group. Within each racial/ethnic group, we ran stratified analyses by income subgroups. RESULTS: The results indicated that Prop 56 was negatively associated with smoking prevalence among full sample, Hispanic, White, and African American adults and negatively associated with smoking intensity among full sample and White smokers. Stratified analyses by race/ethnicity and income showed that Prop 56 was negatively associated with smoking prevalence among low-income full sample and White adults and among middle-income smokers in the full, Hispanic, White, African American, and Asian samples. Prop 56 was negatively associated with smoking intensity among middle-income Hispanic and high-income White smokers. The association between Prop 56 and smoking intensity was positive among high-income African American smokers. CONCLUSION: Prop 56 was associated with a reduction in smoking prevalence across multiple racial/ethnic groups, particularly within the low- and middle-income subgroups. IMPLICATIONS: Our findings indicate that the reduction in smoking prevalence immediately following the implementation of Prop 56 tobacco tax increase was significant across a variety racial/ethnic groups, particularly low- and middle-income subgroups. We found differential responses in smoking prevalence across income groups among Whites but not among racial/ethnic minorities. We found no evidence of any significance association between Proposition 56 and smoking intensity among minorities and economically vulnerable populations, except for middle-income Hispanics. Researchers, policy makers, and advocates should consider the additional merits of targeted, community-based, noneconomic tobacco control interventions in reaching low- and middle-income groups within racial/ethnic minorities.

Differential price-responsiveness of smoking behaviors among non-Hispanic African Americans and non-Hispanic whites in the United States.

BACKGROUND AND AIMS: Non-Hispanic African Americans (African Americans) smoke fewer cigarettes per day (CPD) and are more likely to be non-daily smokers than non-Hispanic whites (whites). Little is known about how changes in cigarette prices might contribute to these differences. This study aimed to measure the price-responsiveness of smoking participation, non-daily smoking among current smokers and smoking intensity among daily or non-daily smokers for African Americans and compare the price-responsiveness estimates with those for whites. DESIGN: Analysis of data from the 2009-14 National Adult Tobacco Surveys and cigarette price data from the Tax Burden on Tobacco report. SETTING: United States. PARTICIPANTS: A total of 19 232 African American and 197 939 white adults aged 18+. MEASUREMENTS: We used a three-part econometric model of cigarette demand to estimate the price-responsiveness of smoking participation, daily versus non-daily smoking and smoking intensity. The model controlled for secular variation, state-level anti-smoking sentiment and smoke-free air laws and socio-demographics. FINDINGS: In 2009-14, 20.2% of African Americans and 17.7% of whites identified as current smokers; 70.2% of African American smokers and 81.4% of white smokers smoked daily. The price elasticity of smoking participation was significant for whites at -0.16 [95% confidence interval (CI) = -0.23, -0.09], indicating that a 10% increase in prices would reduce smoking participation by 1.6%, but not statistically significant for African Americans, and this racial/ethnic differential price responsiveness was not statistically significant. The price elasticity of smoking intensity was statistically significant for African American daily smokers at -0.29 (95% CI = -0.42, -0.16), but not statistically significant for white daily smokers, and this racial/ethnic differential price-responsiveness was statistically significant. The price elasticity of daily versus non-daily smoking among current smokers, and the price elasticity of smoking intensity among non-daily smokers were not statistically significant for either racial/ethnic group. CONCLUSION: In the United States, cigarette price increases may have stronger effects on decreasing daily smokers' consumption among African Americans than among non-Hispanic whites.

Health Care Utilization of Menthol and Non-menthol Cigarette Smokers.

INTRODUCTION: To study the association between health care utilization and menthol cigarette use and whether the association differed between African American (AA) and non-AA smokers. METHODS: We analyzed the three most recent 2005, 2010, and 2015 National Health Interview Survey Cancer Control Supplements. After incorporating propensity score weights adjusting for observed differences between menthol and non-menthol users, we estimated Zero-Inflated Poisson models on hospital nights, emergency department visits, doctor visits, and home visits as a function of menthol use status and other covariates separately for current cigarette smokers and recent quitters (former smokers quitting cigarette smoking ≤ 4 years). RESULTS: Although current menthol smokers smoked fewer cigarettes per day than current non-menthol smokers, they did not differ from current non-menthol smokers in health care utilization. Among recent quitters, those who used to smoke menthol cigarettes had higher odds of having hospital nights than those who used to smoke non-menthol cigarettes. However, we did not find any significant association between menthol use and other health care utilization-emergency department visits, doctor visits, and home visits-among recent quitters. Moreover, compared with non-AA recent quitters, AA recent quitters had higher odds of having home visits, but fewer home visits, if they used to smoke menthol cigarettes. CONCLUSION: Menthol use was associated with greater hospitalization among recent quitters, and the association between home visits and menthol use differed between AA and non-AA recent quitters. IMPLICATIONS: This is the first study that used econometric models to study the association between health care utilization and menthol cigarette use and examine whether the association differed between AA and non-AA smokers. Our study found health care utilization did not differ by menthol use status for current smokers, although current menthol smokers smoked fewer cigarettes per day than current non-menthol smokers. However, we found menthol use was associated with higher odds of having hospital nights for recent quitters. We also found AA recent quitters had a different association between home visits and menthol use compared with non-AA recent quitters.

The impact of e-cigarette and cigarette prices on e-cigarette and cigarette sales in California.

Although numerous studies have examined the impact of cigarette prices on cigarette demand, research examining the impact of e-cigarette and cigarette prices on e-cigarette demand is relatively limited. This study estimated the impact of e-cigarette and cigarette prices on e-cigarette and cigarette sales in California. Using the 2012-2017 Nielsen Retail Scanner Data, we constructed e-cigarette prices, cigarette prices, and per capita e-cigarette and cigarette sales by year, quarter, and Nielsen scantrack market in California. E-cigarettes were categorized as disposable or reusable. Separate fixed-effects models estimated the impact of e-cigarette and cigarette prices on per capita disposable e-cigarette, reusable e-cigarette, and cigarette sales controlling for year, quarter, market, and smoke-free air law coverage. Average prices were $5.86 per pack of 20 cigarettes, $9.80 per disposable e-cigarette, and $19.11 per reusable e-cigarette. When prices of disposable e-cigarettes, reusable e-cigarettes, and cigarettes increased by 1%, per capita sales of the products decreased by 0.37%, 0.20%, and 0.21% respectively. Cigarette prices were positively associated with per capita sales of reusable e-cigarettes, indicating reusable e-cigarettes are substitutes for cigarettes. Reusable e-cigarette prices were positively associated with per capita sales of disposable e-cigarettes, indicating disposable e-cigarettes are substitutes for reusable e-cigarettes. No statistically significant association was found between disposable/reusable e-cigarette prices and cigarette sales. Our results suggest that raising prices of disposable e-cigarettes, reusable e-cigarettes, and cigarettes such as via tobacco excise tax increases would result in reduced sales for the products. Policymakers should consider the substitution between e-cigarettes and cigarettes when designing tobacco control policies.

Smoking Behavior in Low- and High-Income Adults Immediately Following California Proposition 56 Tobacco Tax Increase.

Objectives. To compare the association of California Proposition 56 (Prop 56), which increased the cigarette tax by $2 per pack beginning on April 1, 2017, with smoking behavior among low- and high-income adults.Methods. Drawing on a sample of 17 206 low-income and 21 324 high-income adults aged 21 years or older from the 2012 to 2018 California Behavioral Risk Factor Surveillance System data, we explored 2 outcomes: current smoking prevalence and smoking intensity (average number of cigarettes per day among current smokers). For each income group, we estimated a multivariable logistic regression to analyze the association of Prop 56 with smoking prevalence and a multivariable linear regression to analyze the association of Prop 56 with smoking intensity.Results. Although we observed no association between smoking intensity and Prop 56, we found a statistically significant decline in smoking prevalence among low-income adults following Prop 56. No such association was found among the high-income group.Conclusions. Given that low-income Californians smoke cigarettes at greater rates than those with higher incomes, our results provide evidence that Prop 56 is likely to reduce income disparities in cigarette smoking in California.

Deaths from smoking and from HIV/AIDS among gay and bisexual men in California, 2005-2050.

INTRODUCTION: Deaths from HIV/AIDS have long been of concern to the gay community, but less attention has focused on smoking-attributable deaths despite the relatively high smoking rates among gay and bisexual men. This study compared deaths from HIV/AIDS with smoking-attributable deaths among California gay and bisexual men from 2005 to 2050. METHODS: Smoking-attributable fractions (SAFs) were estimated using smoking prevalence for gay and bisexual men from the 2011-2014 California Health Interview Surveys and published relative risks of death. Smoking-attributable deaths were calculated by multiplying the SAFs by deaths among gay and bisexual men. Deaths from HIV/AIDS among men who have sex with men was obtained from the California Department of Public Health. Future deaths from smoking and HIV/AIDS were projected using regression equations based on time trends. RESULTS: From 2005 to 2014, smoking caused over 6800 deaths among gay and bisexual men, while nearly 9500 died from HIV/AIDS. Mortality from both causes has been falling, but deaths from HIV/AIDS have been falling more rapidly. Projections suggest that in the mid-2040s, more gay/bisexual men will die from smoking than from HIV/AIDS. CONCLUSION: Smoking will surpass HIV/AIDS as a cause of death among gay and bisexual men in California within a few decades. The lesbian, gay, bisexual and transgender (LGBT) community was highly effective in drawing attention and resources to the fight against HIV/AIDS, saving untold lives by hastening effective treatments. Lessons learnt in the fight against AIDS should be used to help fight the tobacco epidemic.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers.

INTRODUCTION: This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts. METHODS: We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices. RESULTS: There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans. CONCLUSIONS: Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed. IMPLICATIONS: The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

Healthcare Costs of Secondhand Smoke Exposure at Home for U.S. Children.

INTRODUCTION: The purpose of this study is to estimate healthcare utilization and healthcare costs due to secondhand smoke exposure at home for children in the U.S. METHODS: Using data from the 2000, 2005, and 2010 U.S. National Health Interview Surveys, the authors analyzed the association between secondhand smoke exposure at home and utilization of three types of healthcare services (hospital nights, emergency room visits, and doctor visits) for children aged 3-14 years (N=16,860). A zero-inflated Poisson regression model was used to control for sociodemographic characteristics and the number of months without health insurance. The authors determined excess healthcare utilization attributable to secondhand smoke exposure at home for children and then estimated annual secondhand smoke-attributable healthcare costs as the product of annual excess healthcare utilization and unit costs obtained from the 2014 Medical Expenditures Panel Survey. This study was conducted from 2016 to 2018. RESULTS: The prevalence of secondhand smoke exposure at home for children in 2000, 2005, and 2010 was 25.0%, 12.3%, and 9.1%, respectively. Secondhand smoke exposure at home was positively associated with emergency room visits, but was not significantly associated with nights at the hospital or doctor visits for children. Secondhand smoke exposure at home for children resulted in an excess of 347,156 emergency room visits in 2000, 124,412 visits in 2005, and 101,570 visits in 2010, which amounted to $215.1 million, $77.1 million, and $62.9 million in excess annual healthcare costs (2014 dollars) in 2000, 2005, and 2010, respectively. CONCLUSIONS: Although U.S. healthcare costs attributable to secondhand smoke exposure at home for children are declining, interventions to reduce secondhand smoke exposure at home for children are still needed to reduce the economic burden attributable to secondhand smoke exposure.

Economic Impact of Financial Incentives and Mailing Nicotine Patches to Help Medicaid Smokers Quit Smoking: A Cost-Benefit Analysis.

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Modelling the impact of a new tobacco product: review of Philip Morris International's Population Health Impact Model as applied to the IQOS heated tobacco product.

OBJECTIVES: We review the Population Health Impact Model (PHIM) developed by Philip Morris International and used in its application to the US Food and Drug Administration (FDA) to market its heated tobacco product (HTP), IQOS, as a modified-risk tobacco product (MRTP). We assess the model against FDA guidelines for MRTP applications and consider more general criteria for evaluating reduced-risk tobacco products. METHODS: In assessing the PHIM against FDA guidelines, we consider two key components of the model: the assumptions implicit in the model (outcomes included, relative harm of the new product vs cigarettes, tobacco-related diseases considered, whether dual or polyuse of the new product is modelled, and what other tobacco products are included) and data used to estimate and validate model parameters (transition rates between non-smoking, cigarette-only smoking, dual use of cigarettes and MRTP, and MRTP-only use; and starting tobacco use prevalence). RESULTS: The PHIM is a dynamic state transition model which models the impact of cigarette and MRTP use on mortality from four tobacco-attributable diseases. The PHIM excludes morbidity, underestimates mortality, excludes tobacco products other than cigarettes, does not include FDA-recommended impacts on non-users and underestimates the impact on other population groups. CONCLUSION: The PHIM underestimates the health impact of HTP products and cannot be used to justify an MRTP claim. An assessment of the impact of a potential MRTP on population health should include a comprehensive measure of health impacts, consideration of all groups impacted, and documented and justifiable assumptions regarding model parameters.