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We estimate the effect of county-level e-cigarette indoor vaping restrictions (IVRs) on infant mortality using United States birth certificates from 2010 to 2015. We estimate difference-in-differences models and find that e-cigarette indoor vaping restrictions increased infant mortality by 0.39 infants per 1,000 live births (12.9%). These effects were disproportionately higher for infants born to younger mothers and in locations with higher baseline levels of prenatal smoking. Infant mortality increased by 34.1% between 100 days to 1 year after IVRs. Infant mortality due to infections and neoplasms were particularly elevated.
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We study the impact of vertical identification card laws, which changed the orientation of driver's licenses and state identification cards from horizontal to vertical for those under 21 years, on teenage tobacco and alcohol use. We study this question using four national datasets (pooled national and state Youth Risk Behavior Surveillance System, National Youth Tobacco Survey, Current Population Survey to Tobacco Use Supplements, and Behavioral Risk Factor Surveillance System). We improve previous databases of vertical ID law implementation by using original archival research to identify the exact date of the law change. We estimate models using standard two-way fixed effects and stacked difference-in-differences that avoid bias from dynamic and heterogeneous treatment effects. Using data through 2021, we do not find evidence of reductions in teenage tobacco and alcohol use. While these laws reduce retail-based purchasing, they also increase social sourcing, thus leading to no net impact on use.
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BACKGROUND AND AIMS: The use of e-cigarettes may influence later smoking uptake in young people. Evidence and gap maps (EGMs) are interactive on-line tools that display the evidence and gaps in a specific area of policy or research. The aim of this study was to map clusters and gaps in evidence exploring the relationship between e-cigarette use or availability and subsequent combustible tobacco use in people aged < 30 years. METHODS: We conducted an EGM of primary studies and systematic reviews. A framework and an interactive EGM was developed in consultation with an expert advisory group. A systematic search of five databases retrieved 9057 records, from which 134 studies were included. Systematic reviews were appraised using AMSTAR-2, and all included studies were coded into the EGM framework resulting in the interactive web-based EGM. A descriptive analysis of key characteristics of the identified evidence clusters and gaps resulted in this report. RESULTS: Studies were completed between 2015 and 2023, with the first systematic reviews being published in 2017. Most studies were conducted in western high-income countries, predominantly the United States. Cohort studies were the most frequently used study design. The evidence is clustered on e-cigarette use as an exposure, with an absolute gap identified for evidence looking into the availability of e-cigarettes and subsequent cessation of cigarette smoking. We also found little evidence analysing equity factors, and little exploring characteristics of e-cigarette devices. CONCLUSIONS: This evidence and gap map (EGM) offers a tool to explore the available evidence regarding the e-cigarette use/availability and later cigarette smoking in people under the age of 30 years at the time of the search. The majority of the 134 reports is from high-income countries, with an uneven geographic distribution. Most of the systematic reviews are of lower quality, suggesting the need for higher-quality reviews. The evidence is clustered around e-cigarette use as an exposure and subsequent frequency/intensity of current combustible tobacco use. Gaps in evidence focusing on e-cigarette availability, as well as on the influence of equity factors may warrant further research. This EGM can support funders and researchers in identifying future research priorities, while guiding practitioners and policymakers to the current evidence base.
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Objectives. To produce a database of private insurance hearing aid mandates in the United States and quantify the share of privately insured individuals covered by a mandate. Methods. We used health-related policy surveillance methods to create a database of private insurance hearing aid mandates through January 2023. We coded salient features of mandates and combined policy data with American Community Survey and Medicare Expenditure Panel Survey-Insurance Component data to estimate the share of privately insured US residents covered by a mandate from 2008 to 2022. Results. A total of 26 states and 1 territory had private insurance hearing aid mandates. We found variability for mandate exceptions, maximum age eligibility, allowable frequency of benefit use, and coverage amounts. Between 2008 and 2022 the proportion of privately insured youths (aged ≤ 18 years) living where there was a private insurance hearing aid mandate increased from 3.4% to 18.7% and the proportion of privately insured adults (19-64 years) increased from 0.3% to 4.6%. Conclusions. Hearing aid mandates cover a small share of US residents. Mandate exceptions in several states limit coverage, particularly for adults. Public Health Implications. A federal mandate would improve hearing aid access. States can also improve access by adopting exception-free mandates with limited utilization management and no age restrictions. (Am J Public Health. 2024;114(4):407-414. https://doi.org/10.2105/AJPH.2023.307551).
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Audífonos , Cobertura del Seguro , Adulto , Adolescente , Humanos , Estados Unidos , Anciano , Epidemiología del Derecho , Medicare , Política de Salud , Seguro de SaludRESUMEN
BACKGROUND: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE: To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES: We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS: The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS: Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.
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Planes de Aranceles por Servicios , Medicare , Humanos , Estados Unidos , Femenino , Anciano , Masculino , Costos de la Atención en Salud , Gastos en Salud , Atención AmbulatoriaRESUMEN
We examine the effect of raising the minimum legal sale age of tobacco to 21 (i.e., "T21"). We estimate difference-in-differences models using the Monitoring the Future (MTF) survey data and Nielsen Retail Scanner data from 2012 to 2019. Outcomes include cigarette and e-cigarette use and sales. We find sizable reductions in e-cigarette and cigarette use for 12th graders. T21 also reduced cigarette sales by 12.4 % and e-cigarette sales by 69.3 % in counties with the highest percent quartile of individuals under 21 years of age. In terms of mechanisms, we find that T21 increases ID checking and perceived risks of using both products.
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Sistemas Electrónicos de Liberación de Nicotina , Productos de Tabaco , Humanos , Adolescente , Uso de Tabaco/epidemiología , Comercio , MercadotecníaRESUMEN
Objectives. To estimate Tobacco-21 policies' relationships to 18- to 20 year-old youth cigarette, cigar, and electronic nicotine delivery system (ENDS) use, and to test for effect modification by policy attributes. Methods. In fall 2022, we used Tobacco 21 Population Coverage Database data to calculate the percentage of state residents covered by state or local Tobacco 21 (T21) laws monthly through June 2020. Matching T21 coverage to Population Assessment of Tobacco and Health and Behavioral Risk Factor Surveillance System data, we used 2-way fixed effect analyses to assess the relationship between T21 laws and 18- to 20-year-old youth cigarette, cigar, and ENDS use, and tested for differences by policy attributes: possession, use, or purchase (PUP) penalties, retailer noncompliance penalties, and compliance check requirements. Results. Increased T21 exposure yielded significant reductions in cigarette and cigar use, as well as in ENDS use, when accounting for policy attributes. These effects were dampened in T21 laws with PUP penalties relative to those without. Conclusions. Tobacco-21 laws yield reductions in 18- to 20-year-old youth cigarette, cigar, and ENDS use, with dampened effects when policies include PUP penalties. Public Health Implications. State policymakers should consider implementing T21 laws without PUP penalties to reduce underage nicotine and tobacco use. (Am J Public Health. 2024;114(1):90-97. https://doi.org/10.2105/AJPH.2023.307447).
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Sistemas Electrónicos de Liberación de Nicotina , Productos de Tabaco , Adolescente , Adulto , Humanos , Adulto Joven , Comercio , Políticas , Fumar/epidemiología , Productos de Tabaco/legislación & jurisprudencia , Uso de Tabaco/epidemiologíaRESUMEN
BACKGROUND: The 2009 Tobacco Control Act granted the US Food and Drug Administration (FDA) regulatory authority over tobacco products, including the ability to authorise modified-risk tobacco product (MRTP) claims. In October 2019, the FDA authorised the first-ever MRTP claim for General Snus, which allowed the product to be marketed as reduced risk (relative to cigarettes). MRTP authorisation may increase otherwise low rates of snus use in the USA (<0.5% for children and adults). METHODS: Using 2017-2021 Nielsen sales data from 19 US states, we conducted a difference-in-differences analysis to determine whether logged unit sales of General Snus were affected by the MRTP authorisation, compared with (1) sales of other snus brands and (2) sales of non-snus smokeless products; we also examined (3) if sales of non-General Snus brands were affected by General Snus's MRTP authorisation, compared with sales of non-snus smokeless tobacco products. RESULTS: Although sales declined in absolute terms, sales of General Snus relative to other snus brands were unchanged after MRTP authorisation (-9.0%, 95% CI -19.6% to 1.60%, p=0.098). However, compared with non-snus smokeless brand sales, sales of General Snus (+14.7%, 95% CI 5.23% to 24.2%, p=0.002) rose after MRTP authorisation. Compared with non-snus smokeless products, sales of non-General Snus brands also rose after MRTP authorisation (+23.7%, 95% CI 9.5% to 38.0%, p=0.001). CONCLUSIONS: Although only General Snus received MRTP authorisation, this designation appears to have slowed declines for the entire snus category. This suggests consumers may make determinations regarding product risk to a product class rather than individual products.
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OBJECTIVE: To examine the association between state Medicaid and private telemedicine coverage requirements and telemedicine use. A secondary objective was to examine whether these policies were associated with health care access. DATA SOURCES AND STUDY SETTING: We used nationally representative survey data from the 2013-2019 Association of American Medical Colleges Consumer Survey of Health Care Access. The sample included Medicaid-enrolled (4492) and privately insured (15,581) adults under age 65. STUDY DESIGN: The study design was a quasi-experimental two-way-fixed-effects difference-in-differences analysis that took advantage of state-level changes in telemedicine coverage requirements during the study period. Separate analyses were conducted for the Medicaid and private requirements. The primary outcome was the past-year use of live video communication. Secondary outcomes included same-day appointment, always able to get needed care, and having enough options for where to go to receive care. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: Medicaid telemedicine coverage requirements were associated with a 6.01 percentage-point increase in the use of live video communication (95% CI, 1.62 to 10.41) and an 11.12 percentage-point increase in always being able to access needed care (95% CI, 3.34 to 18.90). While generally robust to various sensitivity analyses, these findings were somewhat sensitive to included study years. Private coverage requirements were not significantly associated with any of the outcomes considered. CONCLUSIONS: Medicaid telemedicine coverage during 2013-2019 was associated with significant and meaningful increases in telemedicine use and health care access. We did not detect any significant associations for private telemedicine coverage policies. Many states added or expanded telemedicine coverage policies during the COVID-19 pandemic, but states will face decisions about whether to maintain these enhanced policies now that the public health emergency is ending. Understanding the role of state policies in promoting telemedicine use may help inform policymaking efforts going forward.
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COVID-19 , Telemedicina , Adulto , Estados Unidos , Humanos , Anciano , Medicaid , Pandemias , Cobertura del Seguro , Accesibilidad a los Servicios de Salud , Patient Protection and Affordable Care ActRESUMEN
Public health experts caution that legalization of recreational marijuana may normalize smoking and undermine the decades-long achievements of tobacco control policy. However, very little is known about the impact of recreational marijuana laws (RMLs) on adult tobacco use. Using newly available data from the Population Assessment of Tobacco and Health (PATH) and dynamic difference-in-differences and discrete-time hazard approaches, we find that RML adoption increases prior-month marijuana use among adults ages 18-and-older by 2-percentage-points, driven by an increase in marijuana initiation among prior non-users. However, this increase in adult marijuana use does not extend to tobacco use. Rather, we find that RML adoption is associated with a lagged reduction in electronic nicotine delivery systems (ENDS) use, consistent with the hypothesis that ENDS and marijuana are substitutes. Moreover, auxiliary analyses from the National Survey on Drug Use and Health (NSDUH) show that RML adoption is associated with a reduction in adult cigarette smoking. We conclude that RMLs may generate tobacco-related health benefits.
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Cannabis , Sistemas Electrónicos de Liberación de Nicotina , Fumar Marihuana , Uso de la Marihuana , Productos de Tabaco , Humanos , Adulto , Salud Pública , Uso de Tabaco/epidemiología , Fumar Marihuana/epidemiología , Uso de la Marihuana/epidemiologíaRESUMEN
We examine the relationship between contemporaneous fine particulate matter exposure and COVID-19 morbidity and mortality using an instrumental variable approach. Harnessing daily changes in county-level wind direction, we show that arguably exogenous fluctuations in local air quality impact the incidence of confirmed COVID-19 cases and deaths. We find that a one µ g/m 3 increase in PM 2.5, or 15% of the average PM 2.5 concentration in a county, increases the number of same-day confirmed cases by 1.8% from the mean case incidence in a county. A one µ g/m 3 increase in PM 2.5 increases the same-day death rate by just over 4% from the mean. These effects tend to increase in magnitude over longer time horizons and are robust to a host of sensitivity tests. When analyzing potential mechanisms, we also demonstrate that an additional unit of PM 2.5 increases COVID-19-related hospitalizations by 0.8% and use of intensive care units by 0.5% on the same day. Using individual case records, we also show that higher PM 2.5 exposure at the time of case confirmation increases risk of later mechanical ventilation and mortality. These results suggest that air pollution plays an important role in mediating the severity of respiratory syndromes such as COVID-19.
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BACKGROUND: By the end of 2022, nearly 20 million workers in the United States have gained paid-sick-leave coverage from mandates that require employers to provide benefits to qualified workers, including paid time off for the use of preventive services. Although the lack of paid-sick-leave coverage may hinder access to preventive care, current evidence is insufficient to draw meaningful conclusions about its relationship to cancer screening. METHODS: We examined the association between paid-sick-leave mandates and screening for breast and colorectal cancers by comparing changes in 12- and 24-month rates of colorectal-cancer screening and mammography between workers residing in metropolitan statistical areas (MSAs) that have been affected by paid-sick-leave mandates (exposed MSAs) and workers residing in unexposed MSAs. The comparisons were conducted with the use of administrative medical-claims data for approximately 2 million private-sector employees from 2012 through 2019. RESULTS: Paid-sick-leave mandates were present in 61 MSAs in our sample. Screening rates were similar in the exposed and unexposed MSAs before mandate adoption. In the adjusted analysis, cancer-screening rates were higher among workers residing in exposed MSAs than among those in unexposed MSAs by 1.31 percentage points (95% confidence interval [CI], 0.28 to 2.34) for 12-month colorectal cancer screening, 1.56 percentage points (95% CI, 0.33 to 2.79) for 24-month colorectal cancer screening, 1.22 percentage points (95% CI, -0.20 to 2.64) for 12-month mammography, and 2.07 percentage points (95% CI, 0.15 to 3.99) for 24-month mammography. CONCLUSIONS: In a sample of private-sector workers in the United States, cancer-screening rates were higher among those residing in MSAs exposed to paid-sick-leave mandates than among those residing in unexposed MSAs. Our results suggest that a lack of paid-sick-leave coverage presents a barrier to cancer screening. (Funded by the National Cancer Institute.).
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Neoplasias de la Mama , Neoplasias Colorrectales , Detección Precoz del Cáncer , Ausencia por Enfermedad , Humanos , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/economía , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/economía , Detección Precoz del Cáncer/economía , Detección Precoz del Cáncer/estadística & datos numéricos , Mamografía/estadística & datos numéricos , Programas Obligatorios/economía , Programas Obligatorios/legislación & jurisprudencia , Programas Obligatorios/estadística & datos numéricos , Salarios y Beneficios/economía , Salarios y Beneficios/legislación & jurisprudencia , Salarios y Beneficios/estadística & datos numéricos , Ausencia por Enfermedad/economía , Ausencia por Enfermedad/legislación & jurisprudencia , Ausencia por Enfermedad/estadística & datos numéricos , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/estadística & datos numéricosRESUMEN
We study the impact of a temporary U.S. paid sick leave mandate that became effective April 1st, 2020 on self-quarantining, proxied by physical mobility behaviors gleaned from cellular devices. We study this policy using generalized difference-in-differences methods, leveraging pre-policy county-level heterogeneity in the share of workers likely eligible for paid sick leave benefits. We find that the policy leads to increased self-quarantining as proxied by staying home. We also find that COVID-19 confirmed cases decline post-policy.
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COVID-19 , Ausencia por Enfermedad , Humanos , Estados Unidos/epidemiología , Pandemias , Salarios y Beneficios , EmpleoRESUMEN
We study the effects of changing Medicaid reimbursement rates for primary care services on behavioral health outcomes-defined here as mental illness and substance use disorders. Medicaid enrollees are at elevated risk for these, and other, chronic conditions and are likely to have unmet treatment needs. We apply two-way fixed-effects regressions to survey data specifically designed to measure behavioral health outcomes over the period 2010-2016. We find that higher primary care reimbursement rates reduce mental illness and substance use disorders among non-elderly adult Medicaid enrollees, although we interpret findings for substance use disorders with some caution as they may be vulnerable to differential pre-trends. Overall, our findings suggest positive spillovers from a policy designed to target primary care services to behavioral health outcomes.
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Medicaid , Trastornos Relacionados con Sustancias , Adulto , Estados Unidos , Humanos , Persona de Mediana Edad , Cobertura del Seguro , Trastornos Relacionados con Sustancias/terapia , Atención Primaria de Salud , Evaluación de Resultado en la Atención de Salud , Accesibilidad a los Servicios de SaludRESUMEN
Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.
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Sistemas Electrónicos de Liberación de Nicotina , Productos de Tabaco , Humanos , Adolescente , Estados Unidos/epidemiología , Impuestos , Uso de Tabaco , Salud PúblicaRESUMEN
OBJECTIVE: To test the effect of cigarette and e-cigarette taxes on prescriptions for smoking cessation medications. DATA SOURCE: Symphony Health, IDV all-payer prescription claims data for the United States over the period 2009-2017. Prescription fills for smoking cessation products were provided at the patient's age, patient's sex, brand/generic, payment type, year, and quarter levels. STUDY DESIGN: We study the effect of state-level cigarette and e-cigarette tax rates on prescriptions for smoking cessation medications using two-way fixed effect modified difference-in-differences regressions. We also use a multiperiod difference-in-differences estimator robust to bias from dynamic and heterogeneous treatment effects with a staggered policy rollout. DATA COLLECTION/EXTRACTION METHODS: We use fills for Chantix, Zyban, and their generics, as well as Food and Drug Administration-approved nicotine replacement therapies that are paid for by insurance. PRINCIPAL FINDINGS: We observe no statistically significant change in prescription fills following an increase in the e-cigarette tax rate, though we are unable to rule out potentially large effects. However, following a $1.00 increase in the cigarette tax rate, we observe a 1052 increase in prescription fills per 100,000 adults (95% CI: 57, 2046; 4.2% increase). The effect of cigarette taxes on prescription fills was particularly large for 18-34 year-olds. CONCLUSIONS: Our findings suggest that, during a period when e-cigarettes are widely available, cigarette tax increases remain effective in increasing use of these medications, but e-cigarette taxes do not increase use of these medications.
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Sistemas Electrónicos de Liberación de Nicotina , Cese del Hábito de Fumar , Productos de Tabaco , Adulto , Humanos , Estados Unidos , Dispositivos para Dejar de Fumar Tabaco , Impuestos , Medicamentos Genéricos , Comercio , Prevención del Hábito de FumarRESUMEN
INTRODUCTION: E-cigarette taxes have been enacted by 30 states through April 2020. E-cigarette tax schemas vary, in contrast to cigarette taxes in the USA that are levied almost exclusively as excise taxes per pack. Some states use excise taxes on liquid and containers, others ad valorem taxes on wholesale prices and others sales taxes. It is therefore difficult to understand the relative magnitudes of these e-cigarette taxes and the overall e-cigarette tax size relative to the cigarette tax size. OBJECTIVE: To create and publish a database of state and local quarterly e-cigarette taxes from 2010 to 2020, standardised as the rate per millilitre of fluid. METHODS: Using Universal Product Code-level e-cigarette sales from the NielsenIQ Retail Scanner Data along with e-cigarette product characteristics collected from internet searches and visits to e-cigarette retailers, we develop a method to standardise e-cigarette taxes as an equivalent average excise tax rate measured per millilitre of fluid. RESULTS: In 2020, the average American resided in a location with $3.08 in cigarette taxes and $0.34 in e-cigarette taxes (assuming 1 pack=0.7 fluid mL). CONCLUSIONS: The public availability of this state and local standardised e-cigarette tax data will allow tobacco control researchers to study the relationship between e-cigarette taxes and tobacco and related outcomes more effectively.
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Sistemas Electrónicos de Liberación de Nicotina , Industria del Tabaco , Productos de Tabaco , Humanos , Estados Unidos , Fumar , Impuestos , ComercioRESUMEN
AIMS: To estimate whether and to what extent extending indoor smoking restrictions to include electronic cigarettes (ECs) impact the use of ECs and cigarette smoking among adults in the United States. DESIGN: Observational study using a linear probability model and applying a difference-in-differences analysis. SETTING: United States. PARTICIPANTS: People aged 18-54 who lived in US counties where comprehensive indoor smoking laws in bars, restaurants and private work-places have been in place prior to 2010 (n = 45 111 for EC use analysis, n = 75 959 for cigarette use analysis). MEASUREMENTS: Data on cigarette smoking, use of ECs and place of residence from the Tobacco Use Supplement of the Current Population Survey (TUS-CPS 2010-11, 2014-15 and 2018-19) were combined with the American Nonsmokers' Rights Foundation (ANRF) database of state and local indoor smoking and vaping restriction laws. FINDINGS: Indoor vaping restriction (IVR) coverage was not significantly associated with the likelihood of adult EC use [coefficient estimate = 0.001; 95% confidence interval (CI) = -0.009, 0.013, P-value = 0.783]. In addition, IVR coverage was not significantly associated with adult cigarette smoking (coefficient estimate = -0.00; 95% CI = -0.016, 0.015, P-value = 0.954). The non-significant results appeared in different socio-demographic subgroups. CONCLUSIONS: IVRs do not appear to decrease electronic cigarette use among US adults. There is no evidence that IVRs increase or decrease cigarette smoking among US adults.