How do physicians respond to new medical research?

What happens when the findings of a prominent medical study are overturned? Using a medical trial on breech births, we estimate the effect of the reversal of such a medical study on physician choices and infant health outcomes. Using the United States Birth Certificate Records from 1995 to 2010, we employ a difference-in-differences estimator for C-sections, low Apgar, and low birth weight measures. We find that the reversal of a multi-site, high profile, randomized control trial on the appropriate delivery of term breech births, the Term Breech Trial, led to a 15%-23% decline in C-sections for such births at a time when the overall trend in C-sections was rising. We find our largest estimated effects amongst traditionally disadvantaged groups (i.e., non-white, and minimal education). However, we do not find that such a change in practice had significant impacts on infant health. Contrary to prior studies, we find that physicians updated their beliefs quickly, and do indeed adjust to new medical research, particularly young physicians, prior to mandatory policy or professional guidelines.

The Economics of Tobacco Regulation: A Comprehensive Review.

Tobacco regulation has been a major component of health policy in the developed world since the UK Royal College of Physicians' and the US Surgeon General's reports in the 1960s. Such regulation, which has intensified in the past two decades, includes cigarette taxation, place-based smoking bans in areas ranging from bars and restaurants to workplaces, and regulations designed to make tobacco products less desirable. More recently, the availability of alternative products, most notably e-cigarettes, has increased dramatically, and these products are just starting to be regulated. Despite an extensive body of research on tobacco regulations, there remains substantial debate regarding their effectiveness, and ultimately, their impact on economic welfare. We provide the first comprehensive review of the state of research in the economics of tobacco regulation in two decades.

Quantifying brand loyalty: Evidence from the cigarette market.

We exploit a quasi-experiment created when New York State began in 2011 to tax cigarettes sold on Native American Reservations. The regime change represents a unique opportunity to quantify brand loyalty because it almost doubled the price of premium-brand cigarettes, while Native brands were still untaxed. We use data from two different sources-the New York State Adult Tobacco Survey and the Nielsen Homescan Panel. We find that the increase in relative prices led to substantial declines in premium cigarette purchases. However, even among the premium consumers with the most to gain from switching, about three-quarters remained brand loyal.

Does education reduce teen fertility? Evidence from compulsory schooling laws.

While less-educated women are more likely to give birth as teenagers, there is scant evidence the relationship is causal. We investigate this possibility using variation in compulsory schooling laws (CSLs) to identify the impact of formal education on teen fertility at specific ages for a large sample of women drawn from multiple waves of the Canadian Census. We find large negative impacts of education on births for young women aged seventeen and eighteen, but less systematic evidence of an effect after these ages. While our findings are consistent with an "incarceration effect", where school enrollment deters fertility in a contemporaneous manner, we cannot rule out longer-run effects of education on fertility.

Examining the Association Between Physical Activity, Sedentary Behavior and Sport Participation With E-Cigarette Use and Smoking Status in a Large Sample of Canadian Youth.

INTRODUCTION: Youth e-cigarette use is common worldwide, but the profile of e-cigarette users compared with tobacco users is unclear. This study examines how sport participation and activity levels among youth differ between e-cigarette users and smokers. METHODS: Using Canadian data from 38977 grade 9 to 12 students who participated in Year 3 (2014-15) of the COMPASS study, logistic regression models were used to examine the likelihood of sport participation and activity level based on e-cigarette use and smoking status. Pearson's chi-square tests were used to examine subgroup differences by gender. RESULTS: E-cigarette users are more likely to participate in intramural, competitive, and team sports compared to non-users. Current and former smokers are less likely to participate in those sports than non-smokers. Youth e-cigarette users are more likely than non-users to meet the physical activity guidelines. Current smokers are more likely than non-smokers to undertake physical activity at least 60 min daily but less likely than non-smokers to tone at least 3 times per week. Youth e-cigarette users are less likely than non-users to be sedentary less than 2 h daily. Gender differences among males and females show that male e-cigarettes users drive the general relationship. CONCLUSION: Results suggest that e-cigarette users are more likely to engage in physical activity compared to non e-cigarette users. Youth e-cigarette users are more likely to be physically active while the opposite is true for smokers. Although e-cigarettes may be less harmful to health compared to cigarette smoking, the increased uptake among youth of differing profiles should be considered in prevention efforts. IMPLICATIONS: These results highlight the importance of addressing e-cigarette use in youth who undertake health promoting behaviors. Prevention efforts should not focus only on youth who may undertake riskier health habits; e-cigarette prevention programs should go beyond the domain of tobacco control.

An evaluation of school-based e-cigarette control policies' impact on the use of vaping products.

INTRODUCTION: Electronic cigarette (e-cigarette) use among youth is common, and so efforts to regulate its use and availability are continually being made. The school environment represents an important domain for advancing health policy among youth populations. This study examines the impact of school-based e-cigarette control policies on student e-cigarette use in the context of a natural experiment. METHODS: Using three years of longitudinal student and school level data (2013/2014 to 2015/2016), from a sample of 69 secondary schools in Ontario, Canada, a generalized estimating equation approach examined the impact of school-based e-cigarette control policy changes on the prevalence of youth e-cigarette use. The main outcome of interest was current e-cigarette use, while covariates included age, gender, ethnicity, and amount of spending money in dollars per week the student has. Tests of proportion (t-tests) were used to examine whether there were any significant differences in the changes for each intervention school relative to the sample of schools that report no changes in school-level e-cigarette control policies. RESULTS: Estimates from the generalized estimating equation approach suggest that students had lower odds of using e-cigarettes in schools where an e-cigarette control policy was implemented. That is, the e-cigarette control policy decreased the adjusted odds of being an e-cigarette user (OR=0.68; 95% CI: 0.48-0.97). Examining school-specific impact, at four of six schools that had an e-cigarette control policy, the ban on the use of e-cigarettes may have lowered the prevalence of e-cigarette use. CONCLUSIONS: This is the first study to use longitudinal data to study school-level e-cigarette use and the impact of e-cigarette control policy. These results provide new evidence that school-level policies banning the use of e-cigarettes on school property may be effective in reducing e-cigarette use (or preventing it) in their current form, as seen in this natural experiment.

The Impact of Economic Conditions on Healthy Dietary Intake: Evidence From Fluctuations in Canadian Unemployment Rates.

OBJECTIVE: This study examined the impact of economic conditions on fruit and vegetable consumption using multiple waves of the Canadian Community Health Survey. DESIGN: By using metropolitan-area variation in the unemployment rate as a proxy for economic conditions, various measures of fruit and vegetable consumption were regressed on this unemployment rate, using a 2-way fixed effect estimation strategy. MAIN OUTCOME MEASURES: The following measures of fruit and vegetable consumption were considered: (1) total number of times per day respondents ate fruits and vegetables and (2) servings of fruit of vegetable consumption (<5 times/d, 5-10 times/d, and >10 times/d). ANALYSIS: Regression models with location and time-fixed effects were estimated to explore the impact of the unemployment rate with the measures of fruit and vegetable consumption. Pearson's chi-square tests were used to examine subgroup differences by gender. RESULTS: Findings suggested that increases in the unemployment rate (ie, worse economic conditions) reduced fruit and vegetable consumption, and this result was robust across gender and education levels. CONCLUSIONS AND IMPLICATIONS: These findings contribute to a small but important body of literature that focuses specifically on the relationship between economic conditions and fruit and vegetable consumption.

Inappropriate Ambulance Use: A Qualitative Study of Paramedics' Views.

INTRODUCTION: Existing studies of inappropriate ambulance use focus on its extent, employing clinical criteria. Little is known about how front-line paramedics assess appropriateness. This study investigates how paramedics view and judge appropriate versus inappropriate ambulance use. METHODS: We conducted interviews with 19 paramedics working in two regions in southwestern Ontario that were analyzed using grounded theory methods. FINDINGS: While blatantly "inappropriate" use is extraordinary, "misuse" is more common, and paramedics determine misuse largely by interpreting patients' abilities to cope with their situations. Paramedics assess this using multiple patient attributes: patient's age, knowledge of the system, system failures, social support available, presence of transportation alternatives, patient's ability to walk and trial of treatment with home remedies. CONCLUSION: In the future, paramedic-informed, contextual and non-clinical criteria might supplement clinically based criteria for emergency service-use evaluation and may inform more patient-centred policy interventions to reduce ambulance misuse and inappropriate use.

Synthesizing Econometric Evidence: The Case of Demand Elasticity Estimates.

Econometric estimates of the responsiveness of health-related consumer demand to higher prices are often key ingredients for risk policy analysis. We review the potential advantages and challenges of synthesizing econometric evidence on the price-responsiveness of consumer demand. We draw on examples of research on consumer demand for health-related goods, especially cigarettes. We argue that the overarching goal of research synthesis in this context is to provide policy-relevant evidence for broad-brush conclusions. We propose three main criteria to select among research synthesis methods. We discuss how in principle and in current practice synthesis of research on the price-elasticity of smoking meets our proposed criteria. Our analysis of current practice also contributes to academic research on the specific policy question of the effectiveness of higher cigarette prices to reduce smoking. Although we point out challenges and limitations, we believe more work on research synthesis in this area will be productive and important.

Physician response to pay-for-performance: evidence from a natural experiment.

This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care.

Excise tax avoidance: the case of state cigarette taxes.

We conduct an applied welfare economics analysis of cigarette tax avoidance. We develop an extension of the standard formula for the optimal Pigouvian corrective tax to incorporate the possibility that consumers avoid the tax by making purchases in nearby lower tax jurisdictions. To provide a key parameter for our formula, we estimate a structural endogenous switching regression model of border-crossing and cigarette prices. In illustrative calculations, we find that for many states, after taking into account tax avoidance the optimal tax is at least 20% smaller than the standard Pigouvian tax that simply internalizes external costs. Our empirical estimate that tax avoidance strongly responds to the price differential is the main reason for this result. We also use our results to examine the benefits of replacing avoidable state excise taxes with a harder-to-avoid federal excise tax on cigarettes.

Managed care and medical expenditures of Medicare beneficiaries.

This paper investigates the impact of Medicare HMO penetration on the medical care expenditures incurred by Medicare fee-for-service (FFS) enrollees. We find that increasing penetration leads to reduced spending on FFS beneficiaries. In particular, our estimates suggest that the increase in HMO penetration during our study period led to approximately a 7% decline in spending per FFS beneficiary. Similar models for various measures of health care utilization find penetration-induced reductions consistent with our spending estimates. Finally, we present evidence that suggests our estimated spending reductions are driven by beneficiaries who have at least one chronic condition.

Local labor market fluctuations and health: is there a connection and for whom?

We examine the relationship between local labor market conditions and several measures of health and health behaviors for a sample of working-aged men living in the 58 largest metropolitan areas in the United States. We find evidence of procyclical relationships for weight-related health and mental health for men with low ex ante employment probabilities. Separate estimates suggest worsening labor market conditions lead to weight gains and reduced mental health among African-American men and lower mental health among less-educated males. Among our findings, those related to mental health are most pronounced.

Cigarette taxes and the transition from youth to adult smoking: smoking initiation, cessation, and participation.

Many policy makers continue to advocate and adopt cigarette taxes as a public health measure. Most previous individual-level empirical studies of cigarette demand are essentially static analyses of the relationship between the level of taxes and smoking behavior at a point in time. In this study, we use longitudinal data to examine the dynamics of young adults' decisions about smoking initiation and cessation. We develop a simple model to highlight the distinctions between smoking initiation, cessation, and participation. We show that because smoking participation reflects past decisions regarding initiation and cessation, the price elasticity of smoking participation is a weighted average of corresponding initiation and cessation elasticities, a finding that applies more broadly to other addictive substances as well. The paper's remaining contributions are empirical. We use data from the 1992 wave of the National Education Longitudinal Study, when most of the cohort were high school seniors, and data from the 2000 wave, when they were about 26 years old. The results show that the distinction between initiation and cessation is empirically useful. We also contribute new estimates on the tax-responsiveness of young adult smoking, paying careful attention to the possibility of bias if hard-to-observe differences in anti-smoking sentiment are correlated with state cigarette taxes. We find no evidence that higher taxes prevent smoking initiation, but some evidence that higher taxes are associated with increased cessation.

Cigarette taxes and older adult smoking: evidence from recent large tax increases.

While recent evidence casts some doubt, it is generally accepted that the price sensitivity of smoking varies inversely with age. We investigate the responsiveness of older adult smoking using variation from recent historically large cigarette tax increases in the United States. Using data from the Behavioral Risk Factor Surveillance System from 2000 to 2005, we find consistent evidence that higher taxes reduced smoking participation by older adults, especially those who are less educated and live in low-income households. Our findings run contrary to existing evidence which suggests that cessation behavior by older adults is not sensitive to price. Since a large literature suggests smoking cessation even later in life reduces morbidity and increases longevity, our findings may represent substantial gains in health among tax-induced quitters.

Youth smoking, cigarette prices, and anti-smoking sentiment.

In this paper, we develop a new direct measure of state anti-smoking sentiment and merge it with micro-data on youth smoking in 1992 and 2000. The empirical results from the cross-sectional models show two consistent patterns: after controlling for differences in state anti-smoking sentiment, the price of cigarettes has a weak and statistically, insignificant influence on smoking participation, and state anti-smoking sentiment appears to have a potentially important influence on youth smoking participation. The cross-sectional results are corroborated by results from the discrete time hazard models of smoking initiation that include state-fixed effects. However, there is evidence of price-responsiveness in the conditional cigarette demand by youth and young adult smokers.