Preferences for innovations in healthcare delivery models in the Swiss elderly population: a latent class, choice modelling study.

BACKGROUND: With the increasing number of people affected by multiple chronic conditions, it is essential for public-health professionals to promote strategies addressing patient needs for coordinated care. We aim to explore preference heterogeneity for better-coordinated care delivery models in Swiss older adults, and identify profiles of individuals more open to healthcare reforms. METHODS: A DCE (discrete choice experiment) survey was developed online and on paper for the Swiss adults aged 50+, following best practice. To elicit preferences, we estimated a latent class model allowing grouping individuals with similar preferences into distinct classes, and examined what background characteristics contributed to specific class membership. RESULTS: The optimal model identified three classes with different openness to reforms. Class 1 (49%) members were concerned with premium increases and were in favour of integrated care structures with care managed by interprofessional teams. Individuals in class 2 (19%) were younger, open to reforms, and expressed the needs for radical changes within the Swiss healthcare system. Class 3 respondents (32%) were strongly reluctant to changes. CONCLUSIONS: Our study goes beyond average preferences and identifies three distinct population profiles, a majority open to reforms on specific aspects of care delivery, a smallest group in favour radical changes, and a third strongly against changes. Therefore, tailored approaches around healthcare reforms are needed, e.g. explaining the role of interprofessional teams in coordinating care, electronic health records and insurance premium variation.

Stakeholder Engagement in Designing Attributes for a Discrete Choice Experiment With Policy Implications: An Example of 2 Swiss Studies on Healthcare Delivery.

OBJECTIVES: The use of discrete choice experiments (DCEs) has become increasingly popular in health policy development by involving and analyzing the preferences of target groups for different aspects of the policy intervention. In this article, we aim to contribute to the standardization of the process of attribute and attribute level development for DCEs with policy relevance. To do so, we propose and empirically illustrate a framework tool for the development and reporting of attributes and attribute levels, with the systematic engagement of relevant stakeholders. METHODS: The framework tool was kept general to allow its use as a standard reporting approach on the development process of a DCE, involving relevant stakeholders at each stage. The proposed 3-stage process consists of (1) collection, (2) selection, and (3) refinement of the DCE attributes and attribute levels. The application of the framework tool is illustrated by 2 projects, Health2040 and COCONUTS-both concerning the preferences of the Swiss population for the future organization of healthcare. RESULTS: By engaging stakeholders, we identified and included attributes and attribute levels that would not have been identified solely through the existing literature. In addition, including multiple stakeholders from different professional backgrounds ensured that the selected attributes and attribute levels were policy relevant, were applicable in practice, and reflected the opinions of multiple actors in healthcare. CONCLUSION: The proposed framework helps to strengthen the standardization of the reporting on attribute and attribute level development with stakeholder engagement and to guide future research teams designing a DCE with policy implications.

[Teaching health equity in the French-speaking part of Switzerland : inventory in 2023]. / Enseignements sur l'équité en santé en Suisse romande : état des lieux en 2023.

The theme of health equity was for a long time absent or little addressed in the pre- and postgraduate teaching programs of universities and training university hospitals in Switzerland. This gap has gradually been filled by the development and provision of structured teaching on health equity, adapted to the needs of their target audiences. This article aims to highlight a selection of teachings that have emerged in recent years in the French-speaking part of Switzerland.

La thématique de l'équité en santé a été pendant longtemps absente ou peu abordée dans les programmes d'enseignement pré et post-gradué des universités et établissements hospitaliers de formation en Suisse. Cette lacune a été progressivement comblée par le développement et la mise à disposition de formations structurées portant sur l'équité en santé, adaptées aux besoins de leurs publics cibles. Cet article vise à mettre en avant une sélection d'enseignements qui ont vu le jour ces dernières années en Suisse romande.

[Understanding health equity through artificial intelligence The case of Agent-Based Modelling (ABM)]. / Comprendre l'équité en santé grâce à l'intelligence artificielle. L'exemple de l'Agent-Based Modelling (ABM).

Agent-Based Modelling (ABM) is a computer modelling technique that simulates the behaviour and interactions of autonomous agents within a virtual environment. Applied to health equity, this technique allows for a better understanding of the complex social and economic determinants that contribute to health inequities and enables the evaluation of the potential effects of public policies on the latter. Despite some limitations related to the accessibility and quality of health data and the complexity of the models, ABM appears to be a promising tool in the field of health equity, both for researchers in public or community health and for policy makers.

L'Agent-Based Modelling (ABM) est une technique de modélisation informatique qui simule le comportement et les interactions d'agents autonomes au sein d'un environnement virtuel. Appliquée à l'équité en santé, cette technique permet de mieux comprendre les déterminants sociaux et économiques complexes qui contribuent aux iniquités de santé et d'évaluer les effets potentiels de politiques publiques sur ces dernières. Malgré quelques limitations liées notamment à l'accessibilité et la qualité des données de santé et la complexité des modèles, l'ABM apparaît comme un outil prometteur dans le domaine de l'équité en santé, tant pour les chercheurs en santé publique et communautaire que pour les décideurs politiques.

Intensity of care in cancer patients in the last year of life: a retrospective data linkage study.

BACKGROUND: Delivering high-quality palliative and end-of-life care for cancer patients poses major challenges for health services. We examine the intensity of cancer care in England in the last year of life. METHODS: We included cancer decedents aged 65+ who died between January 1, 2010 and December 31, 2017. We analysed healthcare utilisation and costs in the last 12 months of life including hospital-based activities and primary care. RESULTS: Healthcare utilisation and costs increased sharply in the last month of life. Hospital costs were the largest cost elements and decreased with age (0.78, 95% CI: 0.73-0.72, p < 0.005 for age group 90+ compared to age 65-69 and increased substantially with comorbidity burden (2.2, 95% CI: 2.09-2.26, p < 0.005 for those with 7+ comorbidities compared to those with 1-3 comorbidities). The costs were highest for haematological cancers (1.45, 95% CI: 1.38-1.52, p < 0.005) and those living in the London region (1.10, 95% CI: 1.02-1.19, p < 0.005). CONCLUSIONS: Healthcare in the last year of life for advanced cancer patients is costly and offers unclear value to patients and the healthcare system. Further research is needed to understand distinct cancer populations' pathways and experiences before recommendations can be made about the most appropriate models of care.

Interventions aimed at improving healthcare and health education equity for adult d/Deaf patients: a systematic review.

BACKGROUND: d/Deaf people suffer from inequitable access to healthcare and health information. This results in worse health literacy and poorer mental and physical health compared to hearing populations. Various interventions aimed at improving health equity for d/Deaf people have been documented but not systematically analyzed. The purpose of this systematic review is to obtain a global overview of what we know about interventions aimed at improving health equity for d/Deaf people. METHODS: Medline Ovid SP, Embase, CINAHL EBSCO, PsycINFO Ovid SP, Central-Cochrane Library Wiley and Web of Science were searched for relevant studies on access to healthcare and health-related interventions for d/Deaf people following the PRISMA-equity guidelines. We focused on interventions aimed at achieving equitable care and equitable access to health information for d/Deaf people. RESULTS: Forty-six studies were identified and analyzed. Seven categories of interventions facing healthcare or health education inequities emerged: use of Sign Language (1), translation, validation and identification of clinical tools and scales (2), healthcare provider training program (3), development of adapted healthcare facilities (4), online interventions (5), education programs (6) and videos (7). Despite some methodological limitations or lack of data, these interventions seem relevant to improve equity of care and health education for d/Deaf people. CONCLUSION: Interventions that promote healthcare equity, health education amongst d/Deaf patients and healthcare provider awareness of communication barriers and cultural sensitivity show promise in achieving more equitable care for d/Deaf patients. Meaningful engagement of d/Deaf individuals in the conceptualization, implementation and evaluation of health-related interventions is imperative.

Association between continuity of care (COC), healthcare use and costs: what can we learn from claims data? A rapid review.

OBJECTIVE: To describe how longitudinal continuity of care (COC) is measured using claims-based data and to review its association with healthcare use and costs. RESEARCH DESIGN: Rapid review of the literature. METHODS: We searched Medline (PubMed), EMBASE and Cochrane Central, manually checked the references of included studies, and hand-searched websites for potentially additional eligible studies. RESULTS: We included 46 studies conducted in North America, East Asia and Europe, which used 14 COC indicators. Most reported studies (39/46) showed that higher COC was associated with lower healthcare use and costs. Most studies (37/46) adjusted for possible time bias and discussed causality between the outcomes and COC, or at least acknowledged the lack of it as a limitation. CONCLUSIONS: Whereas a wide range of indicators is used to measure COC in claims-based data, associations between COC and healthcare use and costs were consistent, showing lower healthcare use and costs with higher COC. Results were observed in various population groups from multiple countries and settings. Further research is needed to make stronger causal claims.

Detecting and describing heterogeneity in health care cost trajectories among asylum seekers.

BACKGROUND: The mechanism underlying the health care cost trajectories among asylum seekers is not well understood. In the canton of Vaud in Switzerland, a nurse-led health care and medical Network for Migrant Health ("Réseau santé et migration" RESAMI) has established a health care model focusing on the first year after arrival of asylum seekers, called the "community health phase". This model aims to provide tailored care and facilitate integration into the Swiss health care system. The aim of this study is to explore different health care cost trajectories among asylum seekers during this phase and identify the associated factors. METHODS: We detected different patterns of health care cost trajectories using time-series clustering of longitudinal data of asylum seekers in the canton of Vaud in Switzerland. These data included all adult asylum seekers and recipients of emergency aid who entered the canton between 2012 and 2015 and were followed until 2018. The different clusters of health care cost trajectories were then described using a multinomial logistic regression model. RESULTS: We identified a concave, an upward trending, and a downward trending cluster of health care cost trajectories with different characteristics being associated with each cluster. The likelihood of being in the concave cluster is positively associated with coming from the Eastern Mediterranean region or Africa rather than Europe and with a higher share of consultations with an interpreter. The likelihood of being in the upward trending cluster, which accrued the highest costs, is positively associated with 20-24-year-olds rather than older individuals, coming from Europe than any other region and having a mental disorder. In contrast to the other two clusters, the likelihood of being in the downward trending cluster is positively associated with having contacted the RESAMI network within the first month after arrival, which might indicate the potential of early intervention. It is also positively associated with older age and living in a group lodge. CONCLUSIONS: Asylum seekers are heterogeneous in terms of health care cost trajectories. Exploring these differences can help point to possible ways to improve the care and supporting services provided to asylum seekers. Our findings could indicate that early and patient-centered interventions might be well-suited to this aim.

[The health equity issues of an emergency department fee]. / Instauration d'une taxe aux urgences : enjeux d'équité en santé.

In June 2021, the Swiss parliament accepted a legislative proposal calling for the introduction of a fee to fight emergency department (ED) overcrowding. Although this issue remains a major challenge for health policies, the introduction of such a fee raises many questions, notably regarding health equity. However, other more equitable solutions exist: improving the case management of ED frequent users and improving coordination between ED and primary care.

En juin 2021, le Parlement fédéral a accepté une proposition législative demandant l'instauration d'une taxe aux urgences pour lutter contre leur surfréquentation. Bien que cette problématique demeure un enjeu majeur des politiques de santé, l'instauration d'une telle taxe pose de nombreuses questions, notamment d'équité en santé. Pourtant, d'autres solutions existent, en améliorant la prise en charge des usager-ère-s fréquent-e-s des urgences, ainsi que la coordination entre soins primaires et services d'urgences.

Care and cost trajectories of asylum seekers in a nurse-led, patient centered, care network in Switzerland.

BACKGROUND: Switzerland, with its decentralized health system, has seen the emergence of a variety of care models to meet the complex needs of asylum seekers. A network of public and private providers was designed in the canton Vaud, in which a nurse-led team acts as a first contact point to the health system and provides health checks, preventive care, and health education to this population. In addition, the service plays a case management role for more complex and vulnerable patients. While the network has been examined from a clinical angle, we provide the first descriptive evidence on the care and cost trajectories of asylum seekers in the canton. METHODS: We used routinely collected administrative, patient-level data in a Swiss region responsible for 10% of the asylum seekers in the country. We extracted data on all asylum seekers aged 18 or older who entered the network between 2012 and 2015. The data covered all healthcare costs during the period until they left the network, either because they were granted residence, they left the country, or until 31 December 2018. We estimated random effects regression models for costs and consultations within and outside the network for each month of stay in the network. We investigated language barriers in access to care by stratifying the analysis between patients who spoke one of the official Swiss languages or English and patients who did not speak any of these languages. PRINCIPAL FINDINGS: We found that both overall health care costs and contacts with the nurse-led team were relatively high during the first year of stay. Asylum seekers then progressively integrated into the regular health system. Individuals who did not speak the language generally had more contacts with the network and fewer contacts outside. CONCLUSIONS: In this exploratory study, we observe a transition from nurse-led specific care with frequent contacts to care in the regular health system. This leads us to generate the hypothesis that a nurse-led, patient-centered care network for asylum seekers can play an important role in providing primary care during the first year after their arrival and can subsequently help them navigate autonomously within the conventional healthcare system.

Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews.

BACKGROUND: As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings. METHODS: Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions. RESULTS: A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent. CONCLUSIONS: Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.

[COVID-19†: a double punishment for vulnerable households in Switzerland]. / Covid-19†: une double peine pour les ménages les plus vulnérables en Suisse.

The COVID-19 pandemic underlines how vulnerable our societies are to health and economic shocks. It reveals and exacerbates existing inequalities in terms of health status, income, or employment. In Switzerland, as well as globally, most socioeconomically disadvantaged individuals are also the most exposed and vulnerable to the virus, both at work and in their homes. Our aim is to describe the mechanisms through which the pandemic has disproportionally affected some groups of the population. We are particularly interested in the concentration of health and economic risks in specific households and in the public policies implemented to fight the pandemic on the health front while attempting to reduce its economic impact.

La pandémie de Covid-19 est un prisme de lecture révélateur de la vulnérabilité de nos sociétés aux chocs sanitaires et économiques. Elle a pour effet non seulement de mettre en lumière mais aussi d'exacerber les inégalités déjà existantes que ce soit en termes d'état de santé, de revenu ou encore d'accès à l'emploi. En Suisse comme ailleurs, les personnes les plus désavantagées socio-économiquement sont également les plus exposées et vulnérables au virus, tant sur leur lieu de travail que dans le cadre privé. Notre objectif ici est de décrire par quels mécanismes la pandémie a touché de façon différenciée certains groupes de la population. Nous nous intéressons en particulier à la concentration des risques sanitaires et économiques pour certains ménages et aux réponses des pouvoirs publics pour combattre cette épidémie sur le plan sanitaire tout en essayant de réduire son impact économique.

Chemotherapy effectiveness in trial-underrepresented groups with early breast cancer: A retrospective cohort study.

BACKGROUND: Adjuvant chemotherapy in early stage breast cancer has been shown to reduce mortality in a large meta-analysis of over 100 randomised trials. However, these trials largely excluded patients aged 70 years and over or with higher levels of comorbidity. There is therefore uncertainty about whether the effectiveness of adjuvant chemotherapy generalises to these groups, hindering patient and clinician decision-making. This study utilises administrative healthcare data-real world data (RWD)-and econometric methods for causal analysis to estimate treatment effectiveness in these trial-underrepresented groups. METHODS AND FINDINGS: Women with early breast cancer aged 70 years and over and those under 70 years with a high level of comorbidity were identified and their records extracted from Scottish Cancer Registry (2001-2015) data linked to other routine health records. A high level of comorbidity was defined as scoring 1 or more on the Charlson comorbidity index, being in the top decile of inpatient stays, and/or having 5 or more visits to specific outpatient clinics, all within the 5 years preceding breast cancer diagnosis. Propensity score matching (PSM) and instrumental variable (IV) analysis, previously identified as feasible and valid in this setting, were used in conjunction with Cox regression to estimate hazard ratios for death from breast cancer and death from all causes. The analysis adjusts for age, clinical prognostic factors, and socioeconomic deprivation; the IV method may also adjust for unmeasured confounding factors. Cohorts of 9,653 and 7,965 were identified for women aged 70 years and over and those with high comorbidity, respectively. In the ≥70/high comorbidity cohorts, median follow-up was 5.17/6.53 years and there were 1,935/740 deaths from breast cancer. For women aged 70 years and over, the PSM-estimated HR was 0.73 (95% CI 0.64-0.95), while for women with high comorbidity it was 0.67 (95% CI 0.51-0.86). This translates to a mean predicted benefit in terms of overall survival at 10 years of approximately3% (percentage points) and 4%, respectively. A limitation of this analysis is that use of observational data means uncertainty remains both from sampling uncertainty and from potential bias from residual confounding. CONCLUSIONS: The results of this study, as RWD, should be interpreted with caution and in the context of existing and emerging randomised data. The relative effectiveness of adjuvant chemotherapy in reducing mortality in patients with early stage breast cancer appears to be generalisable to the selected trial-underrepresented groups.

Procalcitonin and lung ultrasonography point-of-care testing to decide on antibiotic prescription in patients with lower respiratory tract infection in primary care: protocol of a pragmatic cluster randomized trial.

BACKGROUND: A minority of patients presenting with lower respiratory tract infection (LRTI) to their general practitioner (GP) have community-acquired pneumonia (CAP) and require antibiotic therapy. Identifying them is challenging, because of overlapping symptomatology and low diagnostic performance of chest X-ray. Procalcitonin (PCT) can be safely used to decide on antibiotic prescription in patients with LRTI. Lung ultrasound (LUS) is effective in detecting lung consolidation in pneumonia and might compensate for the lack of specificity of PCT. We hypothesize that combining PCT and LUS, available as point-of care tests (POCT), might reduce antibiotic prescription in LRTIs without impacting patient safety in the primary care setting. METHODS: This is a three-arm pragmatic cluster randomized controlled clinical trial. GPs are randomized either to PCT and LUS-guided antibiotic therapy or to PCT only-guided therapy or to usual care. Consecutive adult patients with an acute cough due to a respiratory infection will be screened and included if they present a clinical pneumonia as defined by European guidelines. Exclusion criteria are previous antibiotics for the current episode, working diagnosis of sinusitis, severe underlying lung disease, severe immunosuppression, hospital admission, pregnancy, inability to provide informed consent and unavailability of the GP. Patients will fill in a 28 day-symptom diary and will be contacted by phone on days 7 and 28. The primary outcome is the proportion of patients prescribed any antibiotic up to day 28. Secondary outcomes include clinical failure by day 7 (death, admission to hospital, absence of amelioration or worsening of relevant symptoms) and by day 28, duration of restricted daily activities, episode duration as defined by symptom score, number of medical visits, number of days with side effects due to antibiotics and a composite outcome combining death, admission to hospital and complications due to LRTI by day 28. An evaluation of the cost-effectiveness and of processes in the clinic using a mixed qualitative and quantitative approach will also be conducted. DISCUSSION: Our intervention targets only patients with clinically suspected CAP who have a higher pretest probability of definite pneumonia. The intervention will not substitute clinical assessment but completes it by introducing new easy-to-perform tests. TRIAL REGISTRATION: The study was registered on the 19th of June 2017 on the clinicaltrials.gov registry using reference number; NCT03191071 .

The impact of governance in primary health care delivery: a systems thinking approach with a European panel.

BACKGROUND: Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS: Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS: A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS: The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.

[Behavioural economics, health and medicine]. / Economie comportementale, santé et médecine.

Economists traditionally describe individuals as well-informed and rational decision-makers. Recent developments in behavioural economics, which lies at the intersection between psychology and economics, challenge these assumptions and describe the common cognitive biases that affect us all. The resulting decision errors are particularly frequent in health and health care given the predominance of uncertainty and the complexity of choices. Interventions aiming at correcting, or exploiting, these biases to improve decisions of citizens, patients, and health professionals have recently emerged. We present here a critical synthesis of findings and discuss potential applications in our health system.

Traditionnellement, les économistes décrivent les individus comme des êtres rationnels et bien informés. Les récents développements de l'économie comportementale, à la frontière entre l'économie et la psychologie, remettent en cause ces hypothèses et mettent en avant les biais cognitifs dont nous souffrons tous. Les erreurs de décision qui en découlent sont particulièrement fréquentes dans le domaine de la santé où l'incertitude prédomine et les choix sont complexes. Des interventions visant à corriger ou à exploiter ces biais pour améliorer les comportements des citoyens, patients et professionnels de santé foisonnent et nous proposons d'en faire ici une synthèse critique et de discuter d'applications éventuelles dans notre système de santé.

Independent validation of the PREDICT breast cancer prognosis prediction tool in 45,789 patients using Scottish Cancer Registry data.

BACKGROUND: PREDICT is a widely used online prognostication and treatment benefit tool for patients with early stage breast cancer. The aim of this study was to conduct an independent validation exercise of the most up-to-date version of the PREDICT algorithm (version 2) using real-world outcomes from the Scottish population of women with breast cancer. METHODS: Patient data were obtained for all Scottish Cancer Registry (SCR) records with a diagnosis of primary invasive breast cancer diagnosed in the period between January 2001 and December 2015. Prognostic scores were calculated using the PREDICT version 2 algorithm. External validity was assessed by statistical analysis of discrimination and calibration. Discrimination was assessed by area under the receiver-operator curve (AUC). Calibration was assessed by comparing the predicted number of deaths to the observed number of deaths across relevant sub-groups. RESULTS: A total of 45,789 eligible cases were selected from 61,437 individual records. AUC statistics ranged from 0.74 to 0.77. Calibration results showed relatively close agreement between predicted and observed deaths. The 5-year complete follow-up sample reported some overestimation (11.5%), while the 10-year complete follow-up sample displayed more limited overestimation (1.7%). CONCLUSIONS: Validation results suggest that the PREDICT tool remains essentially relevant for contemporary patients with early stage breast cancer.

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.

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.