The Baltic and Nordic responses to the first Taliban poppy ban: Implications for Europe & synthetic opioids today.

The 2000-2001 and the 2022-2023 Taliban opium bans were and could be two of the largest ever disruptions to a major illegal drug market. To help understand potential implications of the current ban for Europe, this paper analyzes how opioid markets in seven Baltic and Nordic countries responded to the earlier ban, using literature review, key informant interviews, and secondary data analysis. The seven nations' markets responded in diverse ways, including rebounding with the same drug (heroin in Norway), substitution to a more potent opioid (fentanyl replacing heroin in Estonia), and substitution to one with lower risk of overdose (buprenorphine replacing heroin in Finland). The responses were not instantaneous, but rather evolved, sometimes over several years. This variety suggests that it can be hard to predict how drug markets will respond to disruptions, but two extreme views can be challenged. It would be naive to imagine that drug markets will not adapt to shocks, but also unduly nihilistic to presume that they will always just bounce back with no lasting effects. Substitution to another way of meeting demand is possible, but that does not always negate fully the benefits of disrupting the original market. Nonetheless, there is historical precedent for a European country's opioid market switching to synthetic opioids when heroin supplies were disrupted. Given how much that switch has increased overdose rates in Canada and the United States, that is a serious concern for Europe at present. A period of reduced opioid supply may be a particularly propitious time to expand treatment services (as Norway did in the early 2000s).

Comparing organization-focused and state-focused financing strategies on provider-level reach of a youth substance use treatment model: a mixed-method study.

BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.

Modeling cartel size to inform violence reduction in Mexico.

Estimating stocks and flows is an innovative first step.

America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms.

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. Researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include detail on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education. The primary audience for this study is policymakers, but it should also be useful for foundations looking for opportunities to create change that have often been overlooked. This study can help researchers better consider the full consequences of policy changes and help members of the media identify the dynamics of interactions that deserve more attention.

Cannabis Retail Market Indicators in Five Legal States in the United States: A Public Health Perspective.

PURPOSE: Adult-use cannabis markets are operating in multiple US states and abroad. Sales and licensing data for alcohol and tobacco are often used to understand consumption patterns and evaluate policy changes. Cannabis market data may provide similar insights, although these newly legal markets are complex and evolving, and the state data structures can differ. This study describes variations in market indicators and discusses the utility of cannabis market metrics from a public health perspective. METHODS: We collected data from 5 early-adopting adult-use cannabis states: Alaska, Colorado, Massachusetts, Oregon, and Washington. Analyses focused on licensed retail outlets and retail sales revenues (pretax). Monthly data were collected from the opening of each state's adult-use market through June 2022. Joinpoint software was used to assess state trends and identify points of inflection in trends. Average sales per retailer for June 2019 and June 2022 were compared. Also described are retailers and revenue per population for 2022. FINDINGS: All states showed 4 distinct periods of growth in retail licensee numbers. The greatest increases typically occurred in the first 3 to 4 months. Growth rates slowed to <1% per month for Colorado, Oregon, and Washington at months 25, 24, and 34, respectively. The number of cannabis retailers per 100,000 residents in June 2022 ranged widely, from 16.8 in Oregon to 3.0 in Massachusetts. Colorado, Oregon, and Washington each showed 4 distinct trend periods in adult-use retail sales: early rapid growth lasting <1 year, subsequent varied growth periods, and then declining sales in the most recent months, following early coronavirus disease 2019 period increases. Sales in Alaska and Massachusetts displayed more stable, consistent growth patterns. Sales per state resident for July 2021 to June 2022 also ranged widely, from $382.97 in Alaska to $180.94 in Washington. IMPLICATIONS: We found some consistencies and some variations in both point-in-time measures and trends in states' adult-use cannabis markets. Differences may relate to varied state policies and general contexts (eg, economies). Market data can be useful for public health monitoring, including understanding the effects of policies intended to protect health and safety. States providing publicly accessible cannabis market data create opportunities for such use. Our results underscore the importance of considering individual state regulatory frameworks and implementation timelines in studies of cannabis legalization.

Nine Insights From 10 Years of Legal Cannabis for Nonmedical Purposes.

Whereas the 20th century could be largely characterized as the age of cannabis prohibition, the 21st century may ultimately be known as the era of cannabis legalization. Although several countries and subnational jurisdictions have relaxed laws to allow cannabis to be used for medical purposes, the policy landscape shifted dramatically in 2012 when voters in Colorado and Washington passed ballot initiatives to allow cannabis to be sold to adults for nonmedical purposes. Since then, Canada, Uruguay, and Malta have legalized nonmedical cannabis, and >47% of the US population live in states that have passed laws allowing commercial production and for-profit retail sales. Some countries are now implementing pilot programs for legal supply (eg, the Netherlands, Switzerland), and others are seriously contemplating changing their laws (eg, Germany, Mexico). This commentary offers 9 insights from the first 10 years of legal cannabis for nonmedical purposes, with the goal of informing policy discussions in places considering, implementing, or revising their approach to cannabis legalization: (1) cannabis prices are declining in places with commercial regimes and this matters for several outcomes; (2) noncommercial models are being implemented and seriously considered in some places; (3) policy discussions about cannabis taxes are evolving; (4) the number of cannabis products available in commercial regimes is proliferating; (5) emerging research on higher potency cannabis products raises some public health concerns, but there is still a lot to learn; (6) social equity is playing a larger role in many legalization debates; (7) it takes time to move consumers to the legal market; (8) data collection about cannabis consumption is getting better, but there is much work to do; and (9) ongoing methodological advances should improve our understanding of cannabis policy changes.

Association of an Alcohol Abstinence Program With Mortality in Individuals Arrested for Driving While Alcohol Impaired.

This study examines the associations of 24/7 sobriety programs with reduced alcohol-involved offenses.

Prices and Purchase Sources for Dried Cannabis Flower in the United States, 2019-2020.

Introduction: The price of cannabis has major implications for public health, public safety, social equity, and government revenues. This article examines prices and sources of purchased dried cannabis flower among consumers facing different state laws in the United States. Methods: Repeat cross-sectional survey data were collected from the International Cannabis Policy Study in 2019 and 2020. U.S. respondents were recruited through online commercial panels, ages 16-65, and purchased dried flower in the past year (n=9766). Weighted binary logistic regression models examined legal purchasing in states that had legalized recreational cannabis. Results: Compared with respondents in states with recreational stores, respondents living in "illegal," "medical," and "recreational" states without stores were associated with paying a higher unit price of dried flower (+20.5%, +23.6%, +27.4%, respectively; all p<0.05). The majority of respondents in states with recreational stores last purchased from stores/dispensaries (2019: 66.6%; 2020: 62.0%) and the odds of purchasing legally was greater with each additional year after stores opened (adjusted odds ratio=1.48, 95% confidence interval: 1.37, 1.60). Conclusions: Cannabis prices and purchase behaviors are strongly influenced by its legal status and presence of stores. After states legalize for recreational purposes, it takes multiple years for the legal market to become established as the number of retail stores increase and prices decrease. The findings demonstrate that consumers use sources that they are legally allowed to access, suggesting an increased number of physical retail stores and online delivery services could expand uptake of legal sources in states with recreational cannabis laws.

How much illegally manufactured fentanyl could the U.S. be consuming?

The spread of illegally manufactured opioids, including fentanyl, has brought unprecedented levels of drug overdose deaths in North America. In some markets, illegally manufactured fentanyl (IMF) is essentially displacing heroin, not just being used to adulterate it. It is not possible at this time to provide an accurate point estimate of the amount of IMF consumed in the United States. Yet for various purposes (e.g. assessing changes in production levels and the appropriate role for various supply reduction efforts), it is important to have a sense of scale. This article provides guidance through two thought experiments that provide a hypothetical upper bound on U.S. consumption. The first considers a scenario in which IMF replaces heroin in all illegal opioid markets. The second starts with the number of individuals with an opioid use disorder and considers what total consumption would be if IMF was the only opioid they consumed. Both calculations suggest it is unlikely that the annual consumption of IMF in 2021 could have been more than single digit pure metric tons. For comparison, the most recent best estimates of the amount of cocaine and heroin consumed in the U.S. are 145 and 47 pure metric tons, respectively. The article also raises questions about the limitations of using traditional equianalgesic morphine equivalent dose conversions to estimate the total market consumption of IMF.

Rating the comparative efficacy of state-level cannabis policies on recreational cannabis markets in the United States.

BACKGROUND: Cannabis policy is developing faster than empirical evidence about policy effects. With a panel of experts in substance use policy development and research, we identified key cannabis policies and their provisions enacted by U.S. states; rated their theoretical efficacy in a restrictive form for reducing problematic use and impaired driving in the context of a recreational cannabis market as judged by experts; and rated the strength of evidence for each policy. METHODS: Using a modified Delphi approach, 9 panelists rated the comparative efficacy of 18 state cannabis policies for reducing youth use of cannabis, excessive cannabis use among the general population, and cannabis-impaired driving. Each outcome was rated separately using a Likert scale, and panelists also rated the strength of evidence supporting each efficacy rating. Investigators provided descriptions of each policy so that the nine panelists had similar conceptions of each policy. RESULTS: State monopoly (state owns all production, manufacturing, wholesale, and retail operations) was rated as the most effective policy for all three outcome areas. Restrictions on retail physical availability, taxes, retail price restrictions, and retail operations restrictions were also highly rated for all three outcomes. Policies regulating cannabis businesses and products were judged more effective than policies targeting consumer use and behavior. Panelists reported there was little or no direct evidence from the cannabis policy literature for most of the included policies. CONCLUSION: These ratings can facilitate research as well as policy-making decisions. A relatively small number of policies were judged to be highly effective across all three domains, indicating that for the most part adult excessive use, youth use, and impaired driving can all be reduced with the same set of policies; these policies tended to target the behaviors of businesses rather than consumers. The low levels of direct evidence available to inform policy ratings, as reported by the policy panelists, makes clear the need for ongoing and sustained cannabis policy research.

Comparing two federal financing strategies on penetration and sustainment of the adolescent community reinforcement approach for substance use disorders: protocol for a mixed-method study.

BACKGROUND: Sustained, widespread availability of evidence-based practices (EBPs) is essential to address the public health and societal impacts of adolescent substance use disorders (SUD). There remains a particularly significant need to identify effective financing strategies, which secure and direct financial resources to support the costs associated with EBP implementation and sustainment. This protocol describes a new project comparing two types of U.S. federal grant mechanisms (i.e., a type of financing strategy), which supported the implementation of the Adolescent Community Reinforcement Approach (A-CRA) EBP for SUD, through either organization-focused or state-focused granting of funds. The Exploration-Preparation-Implementation-Sustainment (EPIS) framework will guide our study aims, hypotheses, and selection of measures. METHOD: We will employ a longitudinal, mixed-method (i.e., web surveys, semi-structured interviews, document review, focus groups, administrative data), quasi-experimental design to compare the grant types' outcomes and examine theoretically informed mediators and moderators. Aim 1 will examine the proportion of eligible clinicians certified in A-CRA with adequate fidelity levels (i.e., penetration outcomes) at the end of grant funding. Aim 2 will examine the sustainment of A-CRA up to 5 years post-funding, using a 10-element composite measure of treatment delivery and supervision activities. We will integrate the new data collected from state-focused grant recipients (~85 organizations in 19 states) with previously collected data from organization-focused grant recipients (Hunter et al., Implement Sci 9:104, 2014) (82 organizations in 26 states) for analysis. We will also use sensitivity analyses to characterize the effects of observed and unobserved secular trends in our quasi-experimental design. Finally, aim 3 will use comparative case study methods (integrating diverse quantitative and qualitative measures) to identify and disseminate policy implications about the roles of state- and organization-focused federal grants in efforts to promote adolescent SUD EBP implementation and sustainment. DISCUSSION: The proposed research will have direct, practical implications for behavioral health administrators, policymakers, implementation experts, and the public. It will offer new knowledge that can directly inform financing strategies to support large-scale, sustained EBP delivery in behavioral health-while advancing implementation science through the use of novel methods to study financing strategies and sustainment.

Assessing options for cannabis law reform: A Multi-Criteria Decision Analysis (MCDA) with stakeholders in New Zealand.

BACKGROUND: A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds. AIMS: To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA. METHODS: A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options. RESULTS: The relative weighting of the criteria were: "reducing health and social harm" (46%), "reducing arrests" (31%), "reducing the illegal market" (13%), "expanding treatment" (8%) and "earning tax" (2%). The top ranked reform options were: "government monopoly" (81%), "not-for-profit" (73%) and "strict market regulation" (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The "lightly regulated market" option scored lower largely due its projected greater increase in health and social harm. "Prohibition" ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market. CONCLUSION: Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

Rapid changes in illegally manufactured fentanyl products and prices in the United States.

BACKGROUND AND AIMS: Synthetic opioids, mostly illegally manufactured fentanyl (IMF), were mentioned in 60% of United States (US) drug overdose deaths in 2020, with dramatic variation across states that mirrors variation in IMF supply. However, little is known about IMF markets in the United States and how they are changing. Researchers have previously used data from undercover cocaine, heroin, and methamphetamine purchases and seizures to examine how their use and related harms respond to changes in price and availability. This analysis used US Drug Enforcement Administration (DEA) data to address two questions: (i) "To what extent does IMF supply vary over time and geography?" and (ii) "What has happened to the purity-adjusted price of IMF?" METHODS: We developed descriptive statistics and visualizations using data from 66 713 observations mentioning IMF and/or heroin from the DEA's System to Retrieve Information from Drug Evidence (STRIDE; now STARLIMS) from 2013 to 2021. Price regressions were estimated with city-level fixed effects examining IMF-only powder observations with purity and price information at the low-to-medium wholesale level (>1 g to ≤100 g; n = 964). RESULTS: From 2013 to 2021, the share of heroin and/or IMF observations mentioning IMF grew from near zero to more than two-thirds. The share of heroin observations also containing IMF grew from <1% to ~40%. There is important geographic variation: in California, most IMF seizures involved counterfeit tablets, whereas New York and Massachusetts largely involved powder formulation. The median price per pure gram of IMF powder sold at the >10 to ≤100 g level fell by more than 50% from 2016 to 2021; regression analyses suggested an average annual decline of 17% (P < 0.001). However, this price decline appears to have been driven by observations from the Northeast. CONCLUSIONS: Since 2013, the illegally manufactured fentanyl problem in the United States has become more deadly and more diverse.

Trends in the use of cannabis products in Canada and the USA, 2018 - 2020: Findings from the International Cannabis Policy Study.

BACKGROUND AND AIMS: There is little information on consumption patterns across the diverse range of cannabis product types. This paper examines trends in consumption patterns in Canada and the United States (US) between 2018-2020. DESIGN: Repeat cross-sectional surveys were conducted as part of the International Cannabis Policy Study online survey in 2018 (n=27,024), 2019 (n=45,426), and 2020 (n=45,180). SETTING: Respondents were recruited from commercial panels in Canada and US states that had and had not legalized non-medical cannabis (US 'legal' and 'illegal' states, respectively). PARTICIPANTS: Respondents were male and female participants aged 16-65 years. MEASUREMENTS: Data on frequency and consumption amounts were collected for nine types of cannabis products, including dried flower and processed products (e.g., oils and concentrates). Consumers were also asked about mixing cannabis with tobacco. Socio-demographic information was collected. FINDINGS: Dried flower was the most commonly used product, although use in the past 12 months declined between 2018 and 2020 in Canada (81% to 73%), US legal (78% to 72%) and illegal states (81% to 76%; p<0.05 for all). Prevalence of past 12-month use increased for virtually all other product forms, although prevalence of daily use remained stable across years. In 2020, edibles and vape oils were the most commonly used products after flower. Use of non-flower products was highest in US legal states, although similar trends were observed in all jurisdictions. Males were more likely to report using processed products, and vape oils were the most commonly processed product among 16-20-year-olds. Daily use of cannabis flower increased in US legal and illegal states, and average joint size increased across all jurisdictions over time. CONCLUSIONS: Dried flower remains the dominant product in Canada and the US; however, use of processed cannabis products has increased, with the largest increases observed in legal cannabis markets.

Licensed and unlicensed cannabis outlets in Los Angeles County: the potential implications of location for social equity.

BACKGROUND: Cannabis social equity programs intend to redress inequities experienced by low income and Black, Indigenous, and People of Color (BIPOC) during cannabis prohibition in the United States. In Los Angeles County (LA), the approach is to increase cannabis outlet licensure and employment for low income and BIPOC communities. Monitoring locations of both licensed and unlicensed outlets over time is critical to informing how local social equity programs may affect communities. METHODS: We identified locations of licensed and unlicensed cannabis outlets in LA, from February to April 2019 and again from March to April 2020, and calculated the number and type of outlets by socio-demographic characteristics of census tracts (race/ethnicity, poverty, education, unemployment) using the 2013-2017 American Community Survey 5-year estimates. RESULTS: Licensed outlets increased in LA from 162 in 2019 to 195 in 2020; unlicensed outlets decreased from 286 to 137 over the same time period. In 2020, more licensed outlets were in tracts with majority white residents and adults with at least a bachelor's degree; fewer licensed outlets were in tracts with larger Latinx or Black populations, whereas 71% of unlicensed outlets in 2020 were in low-income tracts, and more unlicensed outlets were in predominately Latinx tracts, high poverty and high unemployment tracts, and tracts with more single female-headed households. CONCLUSIONS: Neighborhood-level analyses are an important first step, but more data are needed for comprehensive evaluations of social equity programs-from individual businesses to the communities living nearby-to understand the impacts on low income and BIPOC populations.

Cannabis legalization and traffic injuries: exploring the role of supply mechanisms.

BACKGROUND AND AIM: In Uruguay, residents age 18 and older seeking legal cannabis must register with the government and choose one of three supply mechanisms: self-cultivation, non-profit cannabis clubs or pharmacies. This is the first paper to measure the association between type of legal cannabis supply mechanism and traffic crashes involving injuries. DESIGN: Ecological study using ordinary least squares regression to examine how department-level variation in registrations (overall and by type) is associated with traffic crashes involving injuries. SETTING: Uruguay. CASES: 532 department-quarters. MEASUREMENTS: Quarterly cannabis registration counts at the department level and incident-level traffic crash data were obtained from government agencies. The analyses controlled for department-level economic and demographic characteristics and, as a robustness check, we included traffic violations involving alcohol for departments reporting this information. Department-level data on crashes, registrations and alcohol violations were denominated by the number of residents ages 18 and older. FINDINGS: From 2013 to 2019, the average number of registrations at the department-quarter level per 10 000 residents age 18 and older for self-cultivation, club membership and pharmacy purchasing were 17.7 (SD = 16.8), 3.6 (SD = 8.6), and 25.1 (SD = 50.4), respectively. In our multivariate regression analyses, we did not find a statistically significant association between the total number of registrations and traffic crashes with injuries (ß = -0.007; P = 0.398; 95% CI = -0.023, 0.01). Analyses focused on the specific supply mechanisms found a consistent, positive and statistically significant association between the number of individuals registered as self-cultivators and the number of traffic crashes with injuries (ß = 0.194; P = 0.008; 95% CI = 0.058, 0.329). Associations for other supply mechanisms were inconsistent across the various model specifications. CONCLUSIONS: In Uruguay, the number of people allowed to self-cultivate cannabis is positively associated with traffic crashes involving injuries. Individual-level analyses are needed to assess better the factors underlying this association.

A Natural Experiment to Test the Effect of Sanction Certainty and Celerity on Substance-Impaired Driving: North Dakota's 24/7 Sobriety Program.

OBJECTIVES: Evaluate the deterrent effect of a program that increases the certainty and celerity of sanction for arrestees ordered to abstain from alcohol and other drugs on substance-impaired driving arrests. METHODS: We examine participant compliance with orders to abstain from alcohol and other drug use via breathalyzer, body-worn continuous alcohol monitoring (CAM) devices, transdermal drug patches, and urinalyses. We then evaluate the impact of the 24/7 Sobriety program on substance-impaired driving arrests. Using variation across counties in the timing of program implementation in North Dakota as a natural experiment, we use differences-in-differences fixed effects Poisson regressions to measure the program's effect on county-level arrests for substance-impaired driving. RESULTS: Over half of participants ordered to abstain from substance use complete 24/7 Sobriety without a detected substance use event. At the county level, the program is associated with a 9 percent reduction in substance-impaired driving arrests after accounting for the impact of oil exploration in the Bakken region, law enforcement intensity, alcohol availability, whether the state's large universities were in session, and socio-demographic characteristics. CONCLUSIONS: The results suggest frequent monitoring combined with increased sanction celerity deters substance use-involved crime. While the results are generally consistent with an earlier study of 24/7 Sobriety in another state, differences in the study outcome measures and implementation choices across states make direct comparisons difficult. More can be learned by conducting randomized controlled trials that vary time on program, testing technology, and/or level of sanction.

Estimating the impact of state cigarette tax rates on smoking behavior: Addressing endogeneity using a natural experiment.

INTRODUCTION: Cigarette excise taxes are a well-established policy lever for reducing tobacco use. However, estimating the effect of taxes on smoking behavior can be confounded by endogeneity concerns such as selection. This study leverages a unique natural experiment -compulsory relocation of U.S. military service members to installations - to estimate the relationship between state cigarette taxes and smoking behavior without concerns about selection into environments. METHODS: The current study uses data from the Department of Defense's 2011 Health-Related Behaviors Survey and 2011 state cigarette excise taxes from the CDC STATE System. Logistic and Poisson regression analyses estimate the cross-sectional associations between state cigarette excise taxes and the following smoking behaviors: current cigarette smoking, frequency of smoking, heaviness of consumption, and cigarette cessation among individuals who smoked while at the current installation. RESULTS: Higher taxes are associated with lower odds of current cigarette smoking (AOR = 0.94; 95 % CI: 0.89-0.98), fewer smoking days per month among current cigarette smokers (IRR = 0.98, 95 % CI 0.97-0.996), and higher likelihood of quitting smoking among individuals who had smoked at their current installation (AOR = 1.14, 95 % CI 1.05-1.25). Taxes are not associated with the number of cigarettes smoked per day among current smokers. CONCLUSIONS: Exogenous assignment to installations in states with higher cigarette taxes is associated with lower likelihood of smoking and greater likelihood of quitting. Findings provide novel evidence in support of a causal impact of cigarette taxes on lower smoking levels among adults.