Standardising the measurement of e-cigarette taxes in the USA, 2010-2020.

INTRODUCTION: E-cigarette taxes have been enacted by 30 states through April 2020. E-cigarette tax schemas vary, in contrast to cigarette taxes in the USA that are levied almost exclusively as excise taxes per pack. Some states use excise taxes on liquid and containers, others ad valorem taxes on wholesale prices and others sales taxes. It is therefore difficult to understand the relative magnitudes of these e-cigarette taxes and the overall e-cigarette tax size relative to the cigarette tax size. OBJECTIVE: To create and publish a database of state and local quarterly e-cigarette taxes from 2010 to 2020, standardised as the rate per millilitre of fluid. METHODS: Using Universal Product Code-level e-cigarette sales from the NielsenIQ Retail Scanner Data along with e-cigarette product characteristics collected from internet searches and visits to e-cigarette retailers, we develop a method to standardise e-cigarette taxes as an equivalent average excise tax rate measured per millilitre of fluid. RESULTS: In 2020, the average American resided in a location with $3.08 in cigarette taxes and $0.34 in e-cigarette taxes (assuming 1 pack=0.7 fluid mL). CONCLUSIONS: The public availability of this state and local standardised e-cigarette tax data will allow tobacco control researchers to study the relationship between e-cigarette taxes and tobacco and related outcomes more effectively.

Cost-Effectiveness of 5 Public Health Approaches to Prevent Eating Disorders.

INTRODUCTION: Eating disorders cause suffering and a high risk of death. Accelerating the translation of research into implementation will require intervention cost-effectiveness estimates. The objective of this study was to estimate the cost-effectiveness of 5 public health approaches to preventing eating disorders among adolescents and young adults. METHODS: Using data from 2001 to 2017, the authors developed a microsimulation model of a closed cohort starting at the age of 10 years and ending at 40 years. In 2021, an analysis was conducted of 5 primary and secondary prevention strategies for eating disorders: school-based screening, primary care‒based screening, school-based universal prevention, excise tax on over-the-counter diet pills, and restriction on youth purchase of over-the-counter diet pills. The authors estimated the reduction in years lived with eating disorders and the increase in quality-adjusted life-years. Intervention costs and net monetary benefit were estimated using a threshold of $100,000/quality-adjusted life year. RESULTS: All the 5 interventions were estimated to be cost-saving compared with the current practice. Discounted per person cost savings (over the 30-year analytic time horizon) ranged from $63 (clinic screening) to $1,102 (school-based universal prevention). Excluding caregiver costs for binge eating disorder and otherwise specified feeding and eating disorders substantially reduced cost savings (e.g., from $1,102 to $149 for the school-based intervention). CONCLUSIONS: A range of public health strategies to reduce the societal burden of eating disorders are likely cost saving. Universal prevention interventions that promote healthy nutrition, physical activity, and media use behaviors without introducing weight stigma may prevent additional negative health outcomes, such as excess weight gain.

The effects of e-cigarette taxes on e-cigarette prices and tobacco product sales: Evidence from retail panel data.

We estimate the effect of e-cigarette tax rates on e-cigarette prices, e-cigarette sales, and sales of other tobacco products using NielsenIQ Retail Scanner data from 2013 to 2019. We find that 90% of e-cigarette taxes are passed on to consumer retail prices. We then estimate reduced form and instrumental variables regressions to examine the effects of e-cigarette and cigarette taxes and prices on sales. We calculate an e-cigarette own-price elasticity of -2.2 and particularly large elasticity of demand for flavored e-cigarettes. Further, we document a cigarette own-price elasticity of -0.4 and positive cross-price elasticities of demand between e-cigarettes and cigarettes, suggesting economic substitution.

The prevalence and excess mortality risk of driving with children.

INTRODUCTION: The presence of passengers can affect the driving behavior of motor-vehicle operators. Child passengers present unique motivations to drive more safely, as well as opportunities to distract drivers. Because motor-vehicle crashes are an important cause of premature childhood mortality, this study assesses whether adult drivers with child passengers are more or less likely to cause a fatal crash. METHOD: Data include fatal crashes involving one or two vehicles from 2007 to 2017 in the U.S. Fatality Analysis Reporting System. We apply methods developed by Levitt and Porter (2001) and Dunn and Tefft (2020) -the LPDT approach- to estimate the risk that adult drivers (21 years or older) with at least one child passenger (15 year or younger) cause a fatal crash relative to adults without child passengers. RESULTS: Childhood crash exposure when traveling with an adult driver is low: 0.78% of vehicle miles traveled by adults included a child passenger. Nevertheless, adult drivers with child passengers were significantly more likely to cause a fatal crash than adult drivers without child passengers. The estimated risk of causing a single-vehicle crash was 6.2 times higher among the full sample of adults, 7.2 times higher among female drivers, and 5.0 times higher among drivers 25-44 years old. CONCLUSIONS: Despite their relatively low crash exposure, child passengers are associated with much greater risk of causing a fatal crash. PRACTICAL APPLICATIONS: This study not only informs about the need to develop interventions to remind parents and adult drivers of the risks associated with driving children, but also reminds researchers about the enormous potential of the LPDT approach when applied to traffic safety issues.

Drinking-and-driving in the United States from 1983-2017: comparing survey and model-based estimates of prevalence.

Although several approaches to estimating prevalence and excess risk exist, each relies on behavioral assumptions that are subject to credible objections. In this article, we compare the assumptions of the most widely accepted approach over the past three decades-results from the National Roadside Survey (NRS)-with a recently revived model-based alternative that estimates these population parameters from the observed distribution of fatal motor vehicle crashes. Comparing estimates of prevalence covering the past four decades, we find that when driver non-response rates in NRS are small, estimates of the prevalence of alcohol-involved driving are nearly identical between methods, suggesting that the underlying behavior assumptions of both models approximately hold. For the past two decades, however, as the rate of driver refusal in the NRS has increased substantially, prevalence estimates between methods have diverged. A counterfactual analysis reveals that the estimates for drinking-and-driving from the model-based approach should be taken as at least as valid as those from the NRS. That is troubling as these methods yield markedly different conclusions about the continued effectiveness of existing traffic safety policy: the NRS finds that the prevalence of drinking-and-driving has fallen monotonically over time, while estimates from the model-based approach suggest that prevalence has plateaued at 15% for the past two decades. More unsettling however, is the conclusion that researchers and policy-makers may know very little about the extent of legally-impaired driving or how it has changed over time.

Correction: The distributional impact of a green payment policy for organic fruit.

[This corrects the article DOI: 10.1371/journal.pone.0211199.].

The distributional impact of a green payment policy for organic fruit.

Consumer spending on organic food products has grown rapidly. Some claim that organics have ecological, equity, and health advantages over conventional food and therefore should be subsidized. Here we explore the distributive impacts of an organic fruit subsidy that reduces the retail price of organic fruit in the US by 10 percent. We estimate the impact of the subsidy on organic fruit demand in a representative poor, middle income, and rich US household using three analytical methods; including two econometric and one machine learning. We do not find strong evidence of regressive redistribution due to our simulated organic fruit subsidy; the poor household's relative reaction to the subsidy is not much different than the reaction at the other two households. However, the infra-marginal savings from the subsidy tend to be larger in richer households.

Impacts of the ACA Medicaid expansion on health behaviors: Evidence from household panel data.

A motivation for increasing health insurance coverage is to improve health outcomes for impacted populations. However, health insurance coverage may alternatively increase risky health behaviors due to ex ante moral hazard, and past research on this issue has led to mixed conclusions. This paper uses a panel of household purchases to estimate the effects of the recent state-level Medicaid expansions resulting from the Affordable Care Act (ACA) on consumption goods that present adverse health risks. We utilize within-household variation to identify whether increases in Medicaid availability impacted household purchase patterns of alcohol, nicotine-related, snack food, and carbonated beverage products. Overall, we find little evidence that the ACA Medicaid expansion led to ex ante moral hazard across any of these products, but we find compelling evidence that the Medicaid expansions reduced cigarette consumption and increased smoking cessation product use among the Medicaid-eligible population.

The relationship between cigarettes and electronic cigarettes: Evidence from household panel data.

We use the Nielsen Consumer Panel to investigate the impact of tobacco control policies on purchases of electronic cigarettes (e-cigarettes), cigarettes, and smoking cessation products. We measure product quantity, product type, nicotine content, and liquid volume of e-cigarettes, and product quantity and nicotine content of cigarettes. Higher cigarette excise taxes decrease both cigarette and e-cigarette purchases, suggesting that cigarettes and e-cigarettes are complements, and higher cigarette excise taxes reduce the aggregate amount of nicotine purchased from cigarettes and e-cigarettes. Cigarette smoke-free air laws decrease cigarette purchases, while e-cigarette smoke-free air laws do not affect cigarette or e-cigarette purchases.

Could a tax on unhealthy products sold for weight loss reduce consumer use? A novel estimation of potential taxation effects.

Abuse of widely available, over-the-counter (OTC) drugs and supplements such as diet pills, laxatives, and diuretics by adolescents for weight control is well-documented, yet manufacturers and retailers can sell them to minors without restriction. The aim of our study was to estimate the effect of added taxation of OTC drugs and dietary supplements sold for weight loss on household purchases of these products. With data from 60,538 U.S. households in the 2012 waves of the Nielsen/IRi National Consumer Panel (NCP) and the Nielsen/IRi Retail Scanner (NRS) datasets, we conducted analyses in 2017 to tally annual quantities and expenditures on OTC drugs or dietary supplements making weight-loss, cleanse/detox, or diuretic claims. We estimated the percent reduction in household purchases due to a simulated 20% added tax on each category. Among the 14,151 households reporting at least one purchase in the three claims categories, a 20% higher average price of weight-loss products was associated with a 5.2% lower purchases of those products. Among households with children ages 12 to 17 years old present, purchases were 17.5% lower, and among households with a daughter present, purchases were 10.3% lower. Taxation may be an effective public health strategy to reduce purchasing of potentially dangerous OTC drugs and supplements sold for weight loss, especially for households that include children ages 12-17 years old or a daughter.

Household expenditures on dietary supplements sold for weight loss, muscle building, and sexual function: Disproportionate burden by gender and income.

Dietary supplements sold for weight loss (WL), muscle building (MB), and sexual function (SF) are not medically recommended. They have been shown to be ineffective in many cases and pose serious health risks to consumers due to adulteration with banned substances, prescription pharmaceuticals, and other dangerous chemicals. Yet no prior research has investigated how these products may disproportionately burden individuals and families by gender and socioeconomic position across households. We investigated household (HH) cost burden of dietary supplements sold for WL, MB, and SF in a cross-sectional study using data from 60,538 U.S. households (HH) in 2012 Nielsen/IRi National Consumer Panel, calculating annual HH expenditures on WL, MB, and SF supplements and expenditures as proportions of total annual HH income. We examined sociodemographic patterns in HH expenditures using Wald tests of mean differences across subgroups. Among HH with any expenditures on WL, MB, or SF supplements, annual HH first and ninth expenditure deciles were, respectively: WL $5.99, $145.36; MB $6.99, $141.93; and SF $4.98, $88.52. Conditional on any purchases of the products, female-male-headed HH spent more on WL supplements and male-headed HH spend more on MB and SF supplements compared to other HH types (p-values < 0.01). High-income ($30,000 < annual income < $100,000), compared to low-income (annual income < $30,000) HH, spent more on all three supplements types (p-values < 0.01); however, proportional to income, low-income HH spent 2-4 times more than high-income HH on WL and MB supplements (p-values < 0.01). Dietary supplements sold for WL, MB, and SF disproportionately burden HH by income and gender.

The Association Between Unhealthy Alcohol Use and Acute Care Expenditures in the 30 Days Following Hospital Discharge Among Older Veterans Affairs Patients with a Medical Condition.

Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.

Preference weights for the spectrum of alcohol use in the U.S. Population.

BACKGROUND: Little is known about the cost-utility of population-based alcohol interventions. One barrier to research has been the lack of preference weights needed to calculate Quality Adjusted Life Years (QALYs). Preference weights can be estimated from measures of health-related quality of life (HRQOL). The objective of this study was to describe preference weights for the full spectrum of alcohol use. METHODS: This cross-sectional study included participants in both the National Health Interview Survey (NHIS; 1999-2002) and the Medical Expenditure Panel Survey (MEPS; 2000-2003). The AUDIT-C alcohol screen was derived from NHIS with scores categorized into 6 groups (0,1-3, 4-5, 6-7, 8-9, 10-12 points), ranging from nondrinking (0) to very severe unhealthy alcohol use (10-12). AUDIT-C scores were mapped to EQ-5D and SF-6D preference weights using the linked datasets and analyses adjusted for demographics. RESULTS: Among 17,440 participants, mean EQ-5D and SF-6D preference weights were 0.82 (95% CI 0.82-0.83) and 0.79 (95% CI 0.79-0.80), respectively. Adjusted EQ-5D preference weights for nondrinking (0.80; 95% CI 0.79-0.81) and moderate unhealthy drinking (0.85; 95% CI 0.84-0.86) were significantly different from low-risk drinking (0.83; 95% CI 0.83-0.84), but no other differences were significant. Results for the SF-6D were similar. CONCLUSIONS: This study provides EQ-5D and SF-6D preference weights for various alcohol use categories in a representative U.S. adult sample. However, neither measure suggested meaningful differences in HRQOL based on AUDIT-C categories. Self-reported alcohol consumption may not be associated with preference weights or generic instruments may not capture alcohol-related differences in HRQOL.

Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge.

BACKGROUND: Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits. METHODS: Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009-10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization. RESULTS: Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n=7,167) and nondrinking (n=357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0-14.6%; and 14.2%, 95% CI 14.1-14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7-13.0%). Only nondrinkers had increased risk for ED visits. CONCLUSIONS: Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits.

Non-linear effects of soda taxes on consumption and weight outcomes.

The potential health impacts of imposing large taxes on soda to improve population health have been of interest for over a decade. As estimates of the effects of existing soda taxes with low rates suggest little health improvements, recent proposals suggest that large taxes may be effective in reducing weight because of non-linear consumption responses or threshold effects. This paper tests this hypothesis in two ways. First, we estimate non-linear effects of taxes using the range of current rates. Second, we leverage the sudden, relatively large soda tax increase in two states during the early 1990s combined with new synthetic control methods useful for comparative case studies. Our findings suggest virtually no evidence of non-linear or threshold effects.

The Dow is Killing Me: Risky Health Behaviors and the Stock Market.

We investigate how risky health behaviors and self-reported health vary with the Dow Jones Industrial Average (DJIA) and during stock market crashes. Because stock market indices are leading indicators of economic performance, this research contributes to our understanding of the macroeconomic determinants of health. Existing studies typically rely on the unemployment rate to proxy for economic performance, but this measure captures only one of many channels through which the economic environment may influence individual health decisions. We find that large, negative monthly DJIA returns, decreases in the level of the DJIA, and stock market crashes are widely associated with worsening self-reported mental health and more cigarette smoking, binge drinking, and fatal car accidents involving alcohol. These results are consistent with predictions from rational addiction models and have implications for research on the association between consumption and stock prices.

Macronutrients and obesity: revisiting the calories in, calories out framework.

Recent clinical research has studied weight responses to varying diet composition, but the contribution of changes in macronutrient intake and physical activity to rising population weight remains controversial. Research on the economics of obesity typically assumes a "calories in, calories out" framework, but a weight production model separating caloric intake into carbohydrates, fat, and protein, has not been explored in an economic framework. To estimate the contributions of changes in macronutrient intake and physical activity to changes in population weight, we conducted dynamic time series and structural VAR analyses of U.S. data between 1974 and 2006 and a panel analysis of 164 countries between 2001 and 2010. Findings from all analyses suggest that increases in carbohydrates are most strongly and positively associated with increases in obesity prevalence even when controlling for changes in total caloric intake and occupation-related physical activity. Our structural VAR results suggest that, on the margin, a 1% increase in carbohydrates intake yields a 1.01 point increase in obesity prevalence over 5 years while an equal percent increase in fat intake decreases obesity prevalence by 0.24 points.

Alcohol-impaired motor vehicle crash risk and the location of alcohol purchase.

Motor vehicle crashes involving alcohol impairment are among the leading causes of mortality and morbidity in the U.S. In this study, we examine how the probability of driving after a binge-drinking episode varies with the location of consumption and type of alcohol consumed. We also investigate the relationship between the location of alcohol purchase and the number of alcohol-impaired fatal motor vehicle crashes. Using multiple datasets that are representative of the U.S. between 2003 and 2009, we find that binge-drinkers are significantly more likely to drive after consuming alcohol at establishments that sell alcohol for on-premises consumption, e.g., from bars or restaurants, particularly after drinking beer. Further, per capita sales of alcohol for off-premises consumption are unrelated to the rate of alcohol-impaired fatal motor vehicle crashes. When disaggregating alcohol types, per capita sales of beer for off-premises consumption are negatively associated with the rate of alcohol-impaired fatal motor vehicle crashes. In contrast, total per capita sales of alcohol from all establishments (on- and off-premises) are positively related to the rate of alcohol-impaired fatal motor vehicle crashes and the magnitude of this relationship is strongest for beer sales. Thus, policies that shift consumption away from bars and restaurants could lead to a decline in the number of motor vehicle crashes.

State-level unemployment and the utilization of preventive medical services.

OBJECTIVE: To study the association between macroeconomic conditions and preventive medical service utilization. DATA SOURCES/STUDY SETTING: Secondary data collection of a survey of the civilian, non-institutionalized population of adults (age 18 and older) in the United States between 1987 and 2010. STUDY DESIGN: Regression analyses that adjust for individual-level demographic and socioeconomic determinants, state and time-fixed effects, and state-specific time trends. DATA COLLECTION/EXTRACTION METHODS: State health departments, with technological and methodological assistance from the Centers for Disease Control and Prevention, conducted a cross-sectional yearly telephone survey using a standardized questionnaire. PRINCIPAL FINDINGS: The use of preventive medical services is procyclical: a 1 percentage point increase in the state-level unemployment rate is associated with a 1.58 percent decrease in the quantity of distinct preventive care services utilized. Women and economically disadvantaged populations are shown to be especially sensitive to macroeconomic fluctuations. CONCLUSIONS: Policy makers should be aware of cyclical changes in preventive care use, particularly among disadvantaged populations, when making challenging budgetary decisions during economic downturns. As physician recommendations can have a strong impact on patients' use, health care providers could increase efforts to persuade patients to seek screening exams and necessary vaccinations during periods of high unemployment.

Has increased body weight made driving safer?

We develop a model of alcohol consumption that incorporates the negative biological relationship between body mass and inebriation conditional on total alcohol consumption. Our model predicts that the elasticity of inebriation with respect to weight is equal to the own-price elasticity of alcohol, consistent with body mass increasing the effective price of inebriation. Given that alcohol is generally considered price inelastic, this result implies that as individuals gain weight, they consume more alcohol but become less inebriated. We test this prediction and find that driver blood alcohol content (BAC) is negatively associated with driver weight. In fatal accidents with driver BAC above 0.10, the driver was 7.8 percentage points less likely to be obese than drivers in fatal accidents that did not involve alcohol. This relationship is not explained by driver attributes (age and sex), driver behaviors (speed and seatbelt use), vehicle attributes (weight class, model year, and number of occupants), or accident context (county of accident, time of day, and day of week).