Occupational differences in the effects of retirement on hospitalizations for mental illness among female workers: Evidence from administrative data in China.

Retirement, a major transition in the life course, may affect many aspects of retirees' well-being, including health and health care utilization. Leveraging differential statutory retirement age (SRA) by occupation for China's urban female workers, we provide some of the first evidence on the causal effect of retirement on hospitalizations attributable to mental illness and its heterogeneity. To address endogeneity in retirement decisions, we take advantage of exogeneity of the differing SRA cut-offs for blue-collar (age 50) and white-collar (age 55) female urban employees. We apply a Fuzzy Regression Discontinuity Design (RDD) around the SRA cut-offs using nationally representative hospital inpatient claims data that cover these workers. We show that blue-collar females incur more hospitalizations for mental illness after retirement, while no similar change is found for white-collar females. Conditional on blue-collar females being hospitalized, probabilities of overall and ER admissions due to mental illness increase by 2.3 and 1.2 percentage points upon retirement, respectively. The effects are primarily driven by patients within the categories of schizophrenia, schizotypal and delusional disorders; and neurotic, stress-related and somatoform disorders. Moreover, the 'Donut' RDD estimates suggest that pent-up demand at retirement unlikely dominates our findings for blue-collar females. Rather, our results lend support to their worsening mental health at retirement. These findings suggest that occupational differences in mental illness and related health care utilization at retirement should be considered when optimizing retirement policy schemes.

Responses to real-world and hypothetical e-cigarette flavor bans among US young adults who use flavored e-cigarettes.

INTRODUCTION: E-cigarette flavor bans could reduce or exacerbate population health harms. To determine how US e-cigarette flavor restrictions might influence tobacco use behavior, this study assesses responses to real-world and hypothetical flavor bans among young adults who use flavored e-cigarettes. METHODS: An online, national survey of young adults ages 18-34 who use flavored e-cigarettes was conducted in 2021 (n=1,253), oversampling states affected by e-cigarette flavor restrictions. Participants were asked about their responses to real-world changes in the availability of flavored e-cigarettes. Unaffected participants were asked to predict their responses under a hypothetical federal e-cigarette flavor ban. RESULTS: The most common response to real-world changes in flavored e-cigarettes availability was to continue vaping (~80%). Among those who exclusively vaped, 12.5% switched to combustible tobacco. Quitting all forms of tobacco was selected by 5.3% of those exclusively vape vs. 4.2% who dual use. Under a hypothetical federal ban, more than half of respondents stated they would continue vaping; 20.9% and 42.5% of those who exclusively vape vs dual use would use combustible tobacco. Quitting all tobacco products was endorsed by 34.5% and 17.2% of those who exclusively vape vs dual use. CONCLUSIONS: Young adults who vape flavored e-cigarettes have mixed responses to e-cigarette flavor bans. Under both real-world and hypothetical e-cigarette flavor bans, most who use flavored e-cigarettes continue vaping. Under a real-world ban, the second most common response among those who exclusively vape is to switch to smoking; under a hypothetical federal ban, it is to quit all tobacco. IMPLICATIONS: This is the first national survey to directly ask young adults who use flavored e-cigarettes about their responses to real-world changes in flavored e-cigarette availability due to state and local flavor restrictions. The survey also asked individuals to predict their responses under a hypothetical federal e-cigarette flavor ban. Most who use flavored e-cigarettes would continue vaping following e-cig flavor restrictions, but many would switch to or continue using combustible tobacco, highlighting potential negative public health consequences of these policies. Policymakers must consider the impact of e-cigarette flavor bans on both e-cigarette and cigarette use.

Responses to real-world and hypothetical menthol flavor bans among US young adults who smoke menthol cigarettes.

INTRODUCTION: Menthol cigarette bans have been implemented in some US states and localities, and a federal ban is being proposed by the FDA. This study asks how young adults who use menthol cigarettes respond to changes in menthol cigarette availability. METHODS: An online survey of young adults ages 18-34 who reported smoking menthol cigarettes on ≥7 of 30 days around Thanksgiving 2019 (n=734), oversampling Massachusetts-the first state with a menthol ban. Participants reported their tobacco use behavior following real-world menthol cigarette bans or predicted their behavior under a hypothetical federal ban. RESULTS: Most respondents who exclusively smoked vs. dual used with e-cigarettes continued smoking/using combustible tobacco following real-world bans (95.3% vs. 86.9%), accessing menthol cigarettes from other jurisdictions. Fewer who smoked exclusively responded by using e-cigarettes compared to those who dual used (3.9% vs. 43.7%). Quitting all tobacco use (i.e. no smoking, vaping, or any tobacco use) was uncommon for both groups (3.6% vs. 9.0%). Under a hypothetical ban, majorities of those who exclusively smoke and who dual use predicted they would continue smoking (72.2% vs. 71.8%); fewer who smoke exclusively would use e-cigarettes compared to those who dual use (14.7% vs. 41.4%). Those who smoke exclusively were more likely to report quitting all tobacco compared to those who dual use (29.6% vs. 12.4%). CONCLUSIONS: Under real-world and hypothetical menthol cigarette bans, most respondents continued smoking. However more young adults continued smoking following real-world bans, reflecting the limitations of local/state restrictions when menthol cigarettes are available in other jurisdictions. IMPLICATIONS: This survey asked young adults who use menthol cigarettes how they responded to real-world changes in the availability of menthol cigarettes; 89% reported continuing to smoke. Those who smoked exclusively were far less likely to respond by switching to e-cigarettes compared to people who dual used both products. Under a hypothetical federal menthol cigarette ban, 72% of young adults predicted that they would continue smoking. Quitting all tobacco was less common in the real-world scenario compared to the hypothetical ban. Access to menthol cigarettes in other jurisdictions and flavored cigars likely dampen the public health benefit of menthol cigarette bans.

Harm reduction for smokers with little to no quit interest: can tobacco policies encourage switching to e-cigarettes?

OBJECTIVE: A pressing tobacco policy concern is how to help smokers who have little interest in quitting cigarettes, a group that often suffers severe health consequences. By switching from cigarettes to e-cigarettes, they could obtain nicotine, potentially with less harm. We examined if policy-relevant attributes of cigarettes/e-cigarettes might encourage these smokers to switch to e-cigarettes. METHODS: An online survey and discrete choice experiment on a nationally-representative sample of adult smokers in the US who reported low interest in quitting (n=2000). We modelled preference heterogeneity using a latent class, latent variable model. We simulated policies that could encourage switching to e-cigarettes. RESULTS: Participants formed two latent classes: (1) those with very strong preferences for their own cigarettes; and (2) those whose choices were more responsive to policies. The latter group's choices were only somewhat responsive to menthol cigarette bans and taxes; the former group's choices were unresponsive. CONCLUSIONS: The policies studied seem unlikely to encourage harm reduction for individuals with little interest in quitting smoking.

Evaluation of Combined Financial Incentives and Deposit Contract Intervention for Smoking Cessation: A Randomized Controlled Trial.

INTRODUCTION: We evaluate whether a combination of financial incentives and deposit contracts improves cessation rates among low- to moderate-income smokers. METHODS: We randomly assigned 311 smokers covered by Medicaid at 12 health clinics in Connecticut to usual care or one of the three treatment arms. Each treatment arm received financial incentives for two months and either (i) nothing further ("incentives only"), (ii) the option to start a deposit contract with incentive earnings after the incentives ended ("commitment"), or (iii) the option to precommit any earned incentives into a deposit contract starting after the incentives ended ("precommitment"). Smoking cessation was confirmed biochemically at two, six, and twelve months. RESULTS: At two, six, and twelve months after baseline, our estimated treatment effects on cessation are positive but imprecise, with confidence intervals containing effect sizes estimated by prior studies of financial incentives alone and deposit contracts alone. At two months, the odds ratio for quitting was 1.4 in the incentive-only condition (95% CI: 0.5 to 3.5), 2.0 for incentives followed by commitment (95% CI: 0.6 to 6.1), and 1.9 for incentives and precommitment (95% CI: 0.7 to 5.3). CONCLUSIONS: A combined incentive and deposit contract program for Medicaid enrollees, with incentives offering up to $300 for smoking cessation and use of support services, produced a positive but imprecisely estimated effect on biochemically verified cessation relative to usual care and with no detectable difference in cessation rates between the different treatment arms.

Who, me? Optimism bias about US teenagers' ability to quit vaping.

BACKGROUND AND AIMS: The vaping rate among US teenagers has doubled in the last 2 years, which may be explained in part by teenagers' optimism that they would have relatively little trouble in quitting. The aim of this study was to estimate the extent to which teenagers exhibited optimism bias, what characteristics are associated with optimism bias and which factors are related to respondents' perceptions of how hard it would be for them to quit. DESIGN: A national, on-line, cross-sectional survey in 2018 using quota sampling. SETTING: United States. PARTICIPANTS: Respondents were 1610 teenagers aged 14-18 years who had ever tried or heard of JUULs or e-cigarettes generally. MEASUREMENTS: Optimism bias was defined as respondents' perceptions of their own difficulty quitting vaping compared with that of an average US person of their own age. Linear regression was used to examine associations between respondents' characteristics with both optimism bias and their own perceived difficulty quitting vaping. FINDINGS: More than 60% of teenagers were optimistically biased about their ability to quit vaping. Smoking (b = -0.69, P < 0.01) and JUULing (b = -0.62, P < 0.01) were negatively associated with optimism bias but reduced-price school lunch eligibility (0.27, P = 0.02) and school satisfaction were positively associated (b = 0.05, P = 0.02). Smoking (b = 0.85, P < 0.01) was associated with an increased perception of the difficulty of quitting. That association was negative for black respondents (b = -0.81, P = 0.01) and those eligible for reduced-priced lunches (b = -0.48, P = 0.01), and positive for Hispanic respondents (b = 0.47, P = 0.04). CONCLUSIONS: On average, US teenagers appear to show optimism bias about their ability to quit vaping, which decreases with smoking and vaping and increases with eligibility for reduced-price school lunches.

Do JUUL and e-cigarette flavours change risk perceptions of adolescents? Evidence from a national survey.

INTRODUCTION: Use of JUULs and e-cigarettes is growing rapidly, particularly among adolescents. Research suggests that flavours may increase the appeal of these products, but little is known about how flavours influence perception. We examined whether youth perceptions about the health risks of JUULs and e-cigarettes vary with flavours. METHODS: We conducted a national survey in 2018 of 1610 high-school students aged 14-18 who had ever heard of either JUULs or e-cigarettes. Respondents were asked to rate the lung cancer risk, the harm of second-hand vapour, potential for addiction and healthiness of differently flavoured JUUL and e-cigarette products. We investigated the relationship among flavour, risk perception and socio-demographic information. RESULTS: We found that risk perceptions for both JUULs and e-cigarettes differ significantly by flavour type. Youths perceive fruit flavours to be less likely to lead to lung cancer (-0.909 (0.065)), have harmful second-hand vapour (-0.933 (0.060)) and be more addictive (1.104 (0.094)) relative to tobacco flavours. Candy, menthol/mint and alcohol flavours show similar patterns of risk association, although the magnitude is slightly smaller than for fruit flavours. CONCLUSIONS: Youths believe that flavours are related to the health risks of both JUULs and e-cigarettes despite the fact that these differences in risk by flavour have not been scientifically or systematically established. A policy concern is that misperceptions based on flavour may result in increased vaping by youths. The findings from this study support the assertion that banning fruit, menthol or mint and sweet flavours could reduce the appeal of JUULs and e-cigarettes to youth, with concomitant health protections.

Leaving Money on the Table? Suboptimal Enrollment in the New Social Pension Program in China.

China's recently implemented New Rural Pension Scheme (NRPS), the largest social pension program in the world, was designed to provide financial protection for its rural population and reduce economic inequities. Yet the impact of this program is mitigated if those eligible fail to enroll. This paper examines the extent to which pension-eligible individuals, and their families, make optimal pension decisions. Families are involved in the NRPS decisions because, in most cases, adult children need to enroll as a prerequisite of their parents' receipt of benefits. We examine the decisions of both those eligible for pension benefits (i.e. over 60 years old) and their adult children. We use the rural sample of the 2012 China Family Panel Study to study determinants of the decision to enroll in NRPS, premiums paid, and time taken to enroll. We find evidence of low and suboptimal pension enrollment by eligible individuals and their families. Suboptimal enrollment takes various forms including failure to switch from the dominated default pension program to NRPS and evidence that families do not make mutually beneficial intra-family decisions. For the older cohort, few individual and family characteristics are significant in enrollment decisions, but village characteristics play an important role. For the younger cohort, more individual-level characteristics are significant, including own and children's education. Village characteristics are important but not as much as for the older cohort. Our finding of suboptimal enrollment is important as it highlights the need for policies to improve enrollment. This paper provides needed information on the extent of the factors relating to suboptimal enrollment.

Tobacco-21 laws and young adult smoking: quasi-experimental evidence.

AIMS: To estimate the impact of tobacco-21 laws on smoking among young adults who are likely to smoke, and consider potential social multiplier effects. Design Quasi-experimental, observational study using new 2016-17 survey data. SETTING: United States. PARTICIPANTS/CASES: A total of 1869 18-22-year-olds who have tried a combustible or electronic cigarette. INTERVENTION AND COMPARATORS: Tobacco-21 laws raise the minimum legal sales age of cigarettes to 21 years. Logistic regressions compared the association between tobacco-21 laws and smoking among 18-20-year-olds with that for 21-22-year-olds. The older age group served as a comparison group that was not bound by these restrictions, but could have been affected by correlated factors. Age 16 peer and parental tobacco use were considered as potential moderators. MEASUREMENTS: Self-reported recent smoking (past 30-day smoking) and current established smoking (recent smoking and life-time consumption of at least 100 cigarettes). FINDINGS: Exposure to tobacco-21 laws yielded a 39% reduction in the odds of both recent smoking [odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.42, 0.89] and current established smoking (OR = 0.61; 95% CI = 0.39, 0.97) among 18-20-year-olds who had ever tried cigarettes. This association exceeded the policy's relationship with smoking among 21-22-year-olds. For current established smoking, the tobacco-21 reduction was amplified among those whose closest friends at age 16 used cigarettes (OR = 0.50; 95% CI = 0.29, 0.87), consistent with peer effects moderating the policy's impact on young adult smoking. CONCLUSIONS: Tobacco-21 laws appear to reduce smoking among 18-20-year-olds who have ever tried cigarettes.

Patterns of Youth Cigarette Experimentation and Onset of Habitual Smoking.

INTRODUCTION: Although research suggests that youth e-cigarette experimentation is associated with later combustible cigarette experimentation, it is unclear how this relates to habitual smoking. This study assesses how minors' patterns of combustible cigarette and e-cigarette experimentation relate to habitual smoking at ages 18-21 years. METHODS: Between November 2016 and May 2017, a cross-sectional, online survey of current and retrospective cigarette use was fielded among individuals aged 18-21 years who had tried combustible cigarettes or e-cigarettes (n=1,424). Logistic regressions tested how experimentation patterns prior to age 18 years related to two indicators of current habitual smoking: daily smoking and current established smoking (past 30-day use among those who had smoked ≥100 cigarettes). RESULTS: Respondents who first tried combustible cigarettes or e-cigarettes as minors (n=1,096) were more likely to be current established users (64%) than those who first experimented at ages 18-21 years (41%). Experimentation patterns in individuals aged <18 years beginning with combustible cigarettes were the most predictive of later smoking. Relative to those who first experimented at ages >17 years (n=328), trying only combustible cigarettes as a minor yielded a 175% increase in one's odds of being an established smoker (AOR=2.75, 95% CI=1.99, 3.79) and a 161% increase for daily smoking (AOR=2.61, 95% CI=1.75, 3.90). Trying combustibles and then e-cigarettes yielded sizable increases in both habitual smoking measures, whereas trying e-cigarettes before combustibles yielded smaller effects. Trying only e-cigarettes as a minor yielded a 78% decrease in both outcomes, relative to those who did not try either product as minors. CONCLUSIONS: Minors who tried combustible cigarettes were more likely to be habitual smokers at ages 18-21 years than those who tried e-cigarettes alone.

The impact of flavors, health risks, secondhand smoke and prices on young adults' cigarette and e-cigarette choices: a discrete choice experiment.

AIMS: To estimate young adults' preferences for cigarettes and e-cigarettes, and how preferences vary by policy-relevant factors. A related aim was to provide information on potential substitution/complementarity across cigarettes and e-cigarettes ahead of policy selection. DESIGN: An online discrete choice experiment (DCE) in which respondents chose their preferred option among cigarettes, two types of e-cigarettes (disposable/reusable) and 'none'. Each cigarette-type was characterized by policy-relevant attributes: flavors, short-term health risks to self, secondhand smoke risks and price. A latent class model identified smoking types that respond differently to these. SETTING: US tobacco market. PARTICIPANTS: A total of 2003 young adults (aged 18-22 years) who ever tried either cigarettes or e-cigarettes, recruited via the survey platform Qualtrics, matched to the 2015 National Health Interview Survey by age, gender, education and census region. MEASUREMENTS: Respondents' DCE choices. FINDINGS: Young adults fell into two broad categories. One latent group, termed 'prefer smoking group', preferred cigarettes and another, 'prefer vaping group', preferred e-cigarettes. The 'prefer smoking group' preferred lower prices and lower health harms more than other attributes. The 'prefer vaping group' valued these, although price less intensely, and valued health and fruit/candy flavors more. CONCLUSION: Banning all flavors in cigarettes and e-cigarettes might improve the health of young adults who ever tried either cigarettes or e-cigarettes. Young adult ever-triers might be deterred from smoking by increasing cigarette prices and encouraged to switch to e-cigarettes by reducing the health harms of e-cigarettes. Reducing health harms of e-cigarettes could also make the 'prefer vaping group' less likely to quit, resulting in increased health harm.

To "vape" or smoke? Experimental evidence on adult smokers.

A growing share of the United States population uses e-cigarettes but the optimal regulation of these controversial products remains an open question. We conduct a discrete choice experiment to investigate how adult tobacco cigarette smokers' demand for e-cigarettes and tobacco cigarettes varies by four attributes: (i) whether e-cigarettes are considered healthier than tobacco cigarettes, (ii) the effectiveness of e-cigarettes as a cessation device, (iii) bans on use in public places, and (iv) price. We find that adult smokers' demand for e-cigarettes is motivated more by health concerns than by the desire to avoid smoking bans or higher prices.

Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment.

OBJECTIVES: To provide the policy-relevant estimates of impacts of alternative flavour bans on preferences and demand for cigarettes and e-cigarettes in adult smokers and recent quitters. METHODS: A best-best discrete choice experiment (DCE) is used to elicit smokers' and recent quitters' preferences for flavours, price, health impact and nicotine level in cigarettes and e-cigarettes. Choice of tobacco products and an opt-out option were examined. An efficient design yielded 36 choice sets. Exploded logit choice models were estimated. Flavour bans are modelled by restricting flavour coefficients in the estimated model. SETTING AND PARTICIPANTS: A sample of 2031 adult smokers and recent quitters was recruited to complete an online survey and DCE. RESULTS: Current smokers and recent quitters, on average, prefer cigarettes and menthol cigarettes over flavoured e-cigarettes. However, there is substantial preference heterogeneity by younger adults (ages 18-25), race/ethnicity and respondents with higher education. Our predictions suggest that a ban on menthol cigarettes would produce the greatest reduction in the choice of cigarettes (-5.2%), but with an accompanying increase in e-cigarettes use (3.8%). In contrast, banning flavours in e-cigarettes, while allowing menthol in cigarettes would result in the greatest increase in the selection of cigarettes (8.3%), and a decline in the use of e-cigarettes (-11.1%). A ban on all flavours, but tobacco in both products would increase 'opting-out' the most (5.2%) but would also increase choice of cigarettes (2.7%) and decrease choice of e-cigarettes (-7.9%). CONCLUSIONS: A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would likely be more effective in reducing the choice of cigarettes. A ban on all flavours in both products would likely reduce the smoking/vaping rates, but the use of cigarettes would be higher than in the status quo. Policy-makers should use these results to guide the choice of flavour bans in light of their stance on the potential health impacts both products.

What factors predict the passage of state-level e-cigarette regulations?

E-cigarettes are controversial products. They may help addicted smokers to consume nicotine in a less harmful manner or to quit tobacco cigarettes entirely, but these products may also entice youth into smoking. This controversy complicates e-cigarette regulation as any regulation may lead to health improvements for some populations, and health declines for other populations. Using data from 2007 to 2016, we examine factors that are plausibly linked with U.S. state e-cigarette regulations. We find that less conservative states are more likely to regulate e-cigarettes and that states with stronger tobacco lobbies are less likely to regulate e-cigarettes. This information can help policymakers as they determine how best to promote public health through regulation.

Exploring Explanations for the Female-Male Earnings Difference Among Registered Nurses in the United States.

Research has shown male registered nurses (RNs) outearn their female colleagues by approximately $5,000 annually. The aim of this study was to explore differences in characteristics of female and male fulltime employed RNs, and to examine whether these differences help account for the female-male earnings gap in nursing. Specifically, the researchers tested whether the gender earnings gap could be explained by differences in career aspiration, workplace experience, time taken out of the labor force for child-rearing, and physical strength. While some evidence suggested motivational differences in career aspirations between female and male RNs exist, evidence supporting other hypotheses was not found. Given the expansion of nurses' roles in health care delivery, serious deliberations of how to respond to the earnings gap in nursing is warranted.

Smaller Cigarette Pack as a Commitment to Smoke Less? Insights from Behavioral Economics.

Cigarettes are commonly sold in packs of 20 units and therefore little is known about the potential impact of pack size on consumption. Using insights from behavioral economics, we suggest that cigarette packs smaller than the standard size may help some smokers cut back and/or quit, consistent with their long-term goals. Results from an online hypothetical purchase experiment conducted in a sample of US smokers reveal that over a third of smokers are willing to pay a price premium to purchase in smaller quantities. Further, a desire to quit smoking and high self-control is associated with preference for a smaller pack. While we provide some preliminary evidence that smaller packs may be beneficial to certain types of smokers, further research should be conducted to assess whether the smaller pack size should be considered in the arsenal of tobacco control policies to help current smokers quit (JEL: I18; I12; D12).

An evaluation of the FDA's analysis of the costs and benefits of the graphic warning label regulation.

The Family Smoking Prevention and Tobacco Control Act of 2009 gave the Food and Drug Administration (FDA) regulatory authority over cigarettes and smokeless tobacco products and authorised it to assert jurisdiction over other tobacco products. As with other Federal agencies, FDA is required to assess the costs and benefits of its significant regulatory actions. To date, FDA has issued economic impact analyses of one proposed and one final rule requiring graphic warning labels (GWLs) on cigarette packaging and, most recently, of a proposed rule that would assert FDA's authority over tobacco products other than cigarettes and smokeless tobacco. Given the controversy over the FDA's approach to assessing net economic benefits in its proposed and final rules on GWLs and the importance of having economic impact analyses prepared in accordance with sound economic analysis, a group of prominent economists met in early 2014 to review that approach and, where indicated, to offer suggestions for an improved analysis. We concluded that the analysis of the impact of GWLs on smoking substantially underestimated the benefits and overestimated the costs, leading the FDA to substantially underestimate the net benefits of the GWLs. We hope that the FDA will find our evaluation useful in subsequent analyses, not only of GWLs but also of other regulations regarding tobacco products. Most of what we discuss applies to all instances of evaluating the costs and benefits of tobacco product regulation and, we believe, should be considered in FDA's future analyses of proposed rules.