Pick your poison

Kevin Lewis

July 14, 2016

Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D

Ashley Bradford & David Bradford

Health Affairs, July 2016, Pages 1230-1236

Legalization of medical marijuana has been one of the most controversial areas of state policy change over the past twenty years. However, little is known about whether medical marijuana is being used clinically to any significant degree. Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented. National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in 2013. The availability of medical marijuana has a significant effect on prescribing patterns and spending in Medicare Part D.


Minimum wages and youth binge drinking

Omer Hoke & Chad Cotti

Empirical Economics, August 2016, Pages 363-381

Binge drinking is associated with many health problems, including unintentional injuries, intentional injuries (e.g., domestic violence, sexual assault), unintended pregnancy, and liver disease. Moreover, high-volume episodic binge drinking is very prevalent among teenagers and young adults. Given that approximately 90 % of the alcohol consumed by youth under the age of 21 in the USA is in the form of binge drinking (Murphy et al. in Addict Res Theory 20(6):456-465, 2012), understanding the determinants of binge drinking behavior, particularly among youth, is important from the perspective of health and policy. In this paper, we explore the relationship between youth binge drinking and an unanticipated determinate of this behavior, minimum wage laws. Using a fixed effects regression model, we observe a positive relationship between minimum wage increases and binge drinking among teenagers. We find that, after accounting for demographic characteristics, different types of risky behaviors, excise tax, state and time fixed effects, and time-varying state effects, a $1 increase in minimum wage increases binge drinking among teenagers by approximately 9 %. Our results support recent findings that minimum wage increases are positively associated with alcohol-related accidents among teenagers (Adam et al. in Rev Econ Stat 94(3):828-840, 2012). Findings suggest that authorities should consider the unexpected impacts that minimum wage increase may have on alcohol consumption among teens and consider parallel policies to help mitigate potential negative consequences.


Alcohol abstention in early adulthood and premature mortality: Do early life factors, social support, and health explain this association?

Rebecca Evans-Polce, Jeremy Staff & Jennifer Maggs

Social Science & Medicine, August 2016, Pages 71-79

Objective: Adult alcohol abstainers have a heightened risk of premature mortality compared to light-to-moderate drinkers. We examine three plausible explanations, other than lack of alcohol, for this observed difference: Abstainers 1) have early life disadvantages that undermine long-term health; 2) lack social support; 3) are less healthy.

Method: In the National Child Development Study, an ongoing national British cohort study of individuals born in 1958, we investigated whether early life disadvantages, lack of social support, and poor physical health reduce or eliminate the elevated risk of mortality through age 51 among those abstaining from alcohol at age 33. Using Cox proportional hazard models in a stepwise approach we examined whether the alcohol-mortality relationship changed when potential confounders were included.

Results: The risk of mortality by age 51 was greater among age-33 abstainers compared to light drinkers (Hazard Ratio [HR] = 2.18; 95% CI = 1.40, 3.40). Including early life disadvantages and social support in the hazard models did not alter these associations (HR = 2.12; 95% CI = 1.27, 3.54). Including physical health in the model resulted in a 25% reduction in risk of death among abstainers, though the difference in risk remained statistically significant (HR = 1.75; 95% CI = 1.04, 2.94).

Conclusions: Abstaining from alcohol in early adulthood, in comparison to light drinking, predicts increased risk for premature mortality, even after accounting for numerous early and young adult confounders. Future research should examine potential moderators of this association.


Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation

Abigail Friedman, William Schpero & Susan Busch

Health Affairs, July 2016, Pages 1176-1183

To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA - increased financial protection - without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.


The Minimum Legal Drinking Age and Morbidity in the US

Christopher Carpenter & Carlos Dobkin

Review of Economics and Statistics, forthcoming

We provide the first evaluation of the effect of the US minimum legal drinking age (MLDA) on nonfatal injuries. Using administrative records from several states and a regression discontinuity approach, we document that inpatient hospital admissions and emergency department (ED) visits increase by 8.4 and 71.3 per 10,000 person-years, respectively, at age 21. These effects are due mainly to an increase in the rate at which young men experience accidental injuries, alcohol overdoses, and injuries inflicted by others. Our results suggest that the literature's disproportionate focus on mortality leads to a significant underestimation the benefits of tighter alcohol control.


E-Cigarettes and Future Cigarette Use

Jessica Barrington-Trimis et al.

Pediatrics, July 2016

Methods: The Children's Health Study is a prospectively followed cohort in Southern California. Data on e-cigarette use were collected in 11th and 12th grade (mean age = 17.4); follow-up data on tobacco product use were collected an average of 16 months later from never-smoking e-cigarette users at initial evaluation (n = 146) and from a sample of never-smoking, never e-cigarette users (n = 152) frequency matched to e-cigarette users on gender, ethnicity, and grade.

Results: Cigarette initiation during follow-up was reported by 40.4% of e-cigarette users (n = 59) and 10.5% of never users (n = 16). E-cigarette users had 6.17 times (95% confidence interval: 3.30-11.6) the odds of initiating cigarettes as never e-cigarette users. Results were robust to adjustment for potential confounders and in analyses restricted to never users of any combustible tobacco product. Associations were stronger in adolescents with no intention of smoking at initial evaluation. E-cigarette users were also more likely to initiate use of any combustible product (odds ratio = 4.98; 95% confidence interval: 2.37-10.4), including hookah, cigars, or pipes.

Conclusions: E-cigarette use in never-smoking youth may increase risk of subsequent initiation of cigarettes and other combustible products during the transition to adulthood when the purchase of tobacco products becomes legal. Stronger associations in participants with no intention of smoking suggests that e-cigarette use was not simply a marker for individuals who would have gone on to smoke regardless of e-cigarette use.


Minimum Ages of Legal Access for Tobacco in the United States From 1863 to 2015

Dorie Apollonio & Stanton Glantz

American Journal of Public Health, July 2016, Pages 1200-1207

In the United States, state laws establish a minimum age of legal access (MLA) for most tobacco products at 18 years. We reviewed the history of these laws with internal tobacco industry documents and newspaper archives from 1860 to 2014. The laws appeared in the 1880s; by 1920, half of states had set MLAs of at least 21 years. After 1920, tobacco industry lobbying eroded them to between 16 and 18 years. By the 1980s, the tobacco industry viewed restoration of higher MLAs as a critical business threat. The industry's political advocacy reflects its assessment that recruiting youth smokers is critical to its survival. The increasing evidence on tobacco addiction suggests that restoring MLAs to 21 years would reduce smoking initiation and prevalence, particularly among those younger than 18 years.


Breaks in Play: Do They Achieve Intended Aims?

Alexander Blaszczynski et al.

Journal of Gambling Studies, June 2016, Pages 789-800

Breaks in play represent a responsible gambling strategy designed to disrupt states of dissociation and enhance the likelihood of drawing attention to a player's session behaviour and expenditure with respect to time and money. The aim of the break in play is to motivate the player to modify or cease gambling so the activity remains within affordable levels. The aim of this study was to investigate whether imposed breaks in play in the absence of accompanying warning messages were effective in reducing cravings. Participants (141 university students) were randomly allocated to one of three conditions: 15 min computer simulated Black Jack play followed by no break, a 3 or 8 min break in play. Participants were administered a battery of measures to assess problem gambling card play, cravings, and dissociation to assess the effects of length of break on cravings. Results indicated that cravings increased rather than decreased with imposed breaks in play, and that the strength of cravings were higher following the eight- compared to 3-min break. It was concluded that breaks in play in isolation might produce counterproductive, unintended, and even perverse effects. The policy implications for responsible gambling strategies is that breaks in play ought to be accompanied with warning and/or personal appraisal messages if optimal effects in reducing within session gambling expenditure are to be achieved.


Underreporting of ecstasy use among high school seniors in the US

Joseph Palamar, Katherine Keyes & Charles Cleland

Drug and Alcohol Dependence, August 2016, Pages 279-282

Background: National surveys suggest ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) use has decreased substantially among adolescents in the US since 2001; however, the recent phenomenon of "Molly" (ecstasy marketed as "pure MDMA") may be leading to underreporting of use as not all users are aware that "Molly" is a form of ecstasy.

Methods: We examined 2014 data from Monitoring the Future, a nationally representative survey of high school seniors in the US (N = 6250, modal age: 18). Three randomly distributed survey forms asked about ecstasy use, and one included "Molly" in the definition. Self-reported lifetime, 12-month, and 30-day ecstasy use were compared to determine whether including "Molly" in the definition was associated with higher prevalence or frequency of use.

Results: The form including "Molly" in the definition had significantly higher prevalence than the two (combined) forms that did not. Lifetime use (8.0% vs. 5.5%) and 12-month use (5.1% vs. 3.6%) were significantly higher with "Molly" in the definition. Lifetime prevalence remained higher with "Molly" in the definition when controlling for correlates of ecstasy use; however, 12-month use did not. Differences in prevalence were associated with lifetime occasions of use, with lower concordance between forms at lower levels of lifetime occasions (e.g., 1-2 times). Survey form was not related to number of times used among more frequent users.

Conclusions: Prevalence of ecstasy use appears to be underestimated when "Molly" is not included in the definition of ecstasy/MDMA. Surveys should include "Molly" in the definition of ecstasy to more adequately assess prevalence of use.


Decline In Public Substance Use Disorder Treatment Centers Most Serious In Counties With High Shares Of Black Residents

Janet Cummings, Hefei Wen & Michelle Ko

Health Affairs, June 2016, Pages 1036-1044

Previous research has associated declines in health care resources such as hospitals and trauma centers with communities' racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002-10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2 percent, whereas the number of private for-profit facilities grew 19.1 percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.


The Share Price Effect of CVS Health's Announcement to Stop Selling Tobacco: A Comparative Case Study Using Synthetic Controls

Martin Andersen & Sebastian Bauhoff

Forum for Health Economics and Policy, forthcoming

We study how the announcement by CVS Health, a large US-based pharmacy chain, to stop selling tobacco products affected its share price and that of its close competitors, as well as major tobacco companies. Combining event study and synthetic control methodologies we compare measures of CVS's stock market valuation with those of a peer group consisting of large publicly listed firms that are part of Standard & Poor's S&P 500 stock market index. CVS's announcement is associated with a short-term decrease in its share price, whereas close competitors have benefitted from CVS' decision. We also find a negative share price effect for Altria, the largest US domestic tobacco firm. Overall our findings are consistent with markets expecting consumers to shift from CVS to alternative outlets in the short-run, and interpreting CVS' decision to drop tobacco products as signal that other firms may follow suit.


Social anxiety and alcohol-related sexual victimization: A longitudinal pilot study of college women

Amie Schry, Brenna Maddox & Susan White

Addictive Behaviors, October 2016, Pages 117-120

Objective: We sought to examine social anxiety as a risk factor for alcohol-related sexual victimization among college women. Participants: Women (Time 1: n = 574; Time 2: n = 88) who reported consuming alcohol at least once during the assessment timeframe participated.

Method: Social anxiety, alcohol use, alcohol-related consequences, and sexual victimization were assessed twice, four months apart. Logistic regressions were used to examine social anxiety as a risk factor for alcohol-related sexual victimization at both time points.

Results: Longitudinally, women high in social anxiety were approximately three times more likely to endorse unwanted alcohol-related sexual experiences compared to women with low to moderate social anxiety.

Conclusions: This study suggests social anxiety, a modifiable construct, increases risk for alcohol-related sexual victimization among college women. Implications for clinicians and risk-reduction program developers are discussed.


Changes in inmates' substance use and dependence from pre-incarceration to one year post-release

June Tangney et al.

Journal of Criminal Justice, September 2016, Pages 228-238

Methods: In Study 1, professionals (n = 162) and laypersons (n = 50) predicted how jail inmates' substance misuse would change from pre-incarceration to post-release. In Study 2, a longitudinal study of 305 jail inmates, we examined actual changes in substance use and dependence from pre-incarceration to the first year post-incarceration, as well as whether changes varied as a function of demographic, criminal justice, treatment, and personality factors.

Results: Professionals and laypersons predicted little change in substance misuse whereas, in fact, inmates' frequency of substance use and dependence decreased substantially from pre-incarceration to post-release. Sharper decreases were observed for inmates who were female, younger, more educated, serving longer sentences, enrolled in substance abuse treatment, high in shame-proneness, and low in criminogenic thinking. Race, first time incarceration, transfer to other correctional facilities, mandated community supervision (probation), and guilt-proneness did not predict changes in substance use or dependence.

Conclusions: Although substance misuse decreased, this remains a population high in need of substance abuse treatment both upon arrest and at one year post-incarceration; 60% of former inmates met at least one DSM-IV criterion for substance dependence at one year post-release.


Examination of the Divergence in Trends for Adolescent Marijuana Use and Marijuana-Specific Risk Factors in Washington State

Charles Fleming et al.

Journal of Adolescent Health, forthcoming

Methods: Data were from 2000 to 2014 biennial Washington State surveys of 10th-grade students. First, we assessed whether associations between marijuana use and marijuana-specific risk factors have weakened over time. Second, we examined whether decreases in alcohol and cigarette use can account for the lack of expected increase in marijuana use prevalence.

Results: Despite stability in marijuana use prevalence, there were increases in marijuana-specific risk factors of low perceived harm, youth favorable attitudes about use, and perceived community attitudes favorable to use. Associations between marijuana use and marijuana use predictors varied little across time; if anything, the positive association between low perceived harm and marijuana use grew stronger. Decreases in prevalence of alcohol and cigarette use largely accounted for stability in marijuana use during a period when marijuana risk factors increased.

Conclusions: Decreases in other types of substance use or in the underlying, common risk for substance use may have mitigated effects of increases in marijuana-specific risk factors.


Decreased Diversion by Doctor-Shopping for a Reformulated Extended Release Oxycodone Product

Howard Chilcoat et al.

Drug and Alcohol Dependence, August 2016, Pages 221-228

Background: Doctor-shopping (obtaining prescriptions from multiple prescribers/pharmacies) for opioid analgesics produces a supply for diversion and abuse, and represents a major public health issue.

Methods: An open cohort study assessed changes in doctor-shopping in the U.S. for a brand extended release (ER) oxycodone product (OxyContin) and comparator opioids before (July, 2009 to June, 2010) versus after (January, 2011 to June, 2013) introduction of reformulated brand ER oxycodone with abuse-deterrent properties, using IMS LRx longitudinal data covering >150 million patients and 65% of retail U.S. prescriptions.

Results: After its reformulation, the rate of doctor-shopping decreased 50% (for 2+ prescribers/3+ pharmacies) for brand ER oxycodone, but not for comparators. The largest decreases in rates occurred among young adults (73%), those paying with cash (61%) and those receiving the highest available dose (62%), with a 90% decrease when stratifying by all three characteristics. The magnitude of doctor-shopping reductions increased with increasing number of prescribers/pharmacies (eg, 75% reduction for ?2 prescribers/ ? 4 pharmacies).

Conclusions: The rate of doctor-shopping for brand ER oxycodone decreased substantially after its reformulation, which did not occur for other prescription opioids. The largest reductions in doctor-shopping occurred with characteristics associated with higher abuse risk such as youth, cash payment and high dose, and with more specific thresholds of doctor-shopping. A higher prescriber and/or pharmacy threshold also increased the magnitude of the decrease, suggesting that it better captured the effect of the reformulation on actual doctor-shoppers.


History of abuse and risky sex among substance users: The role of rejection sensitivity and the need to belong

Jacqueline Woerner et al.

Addictive Behaviors, November 2016, Pages 73-78

This study investigates abuse and rejection sensitivity as important correlates of risky sexual behavior in the context of substance use. Victims of abuse may experience heightened sensitivity to acute social rejection and consequently engage in risky sexual behavior in an attempt to restore belonging. Data were collected from 258 patients at a substance use treatment facility in Washington, D.C. Participants' history of abuse and risky sexual behavior were assessed via self-report. To test the mediating role of rejection sensitivity, participants completed a social rejection task (Cyberball) and responded to a questionnaire assessing their reaction to the rejection experience. General risk-taking propensity was assessed using a computerized lab measure. Abuse was associated with increased rejection sensitivity (B = 0.124, SE = 0.040, p = 0.002), which was in turn associated with increased risky sex (B = 0.06, SE = 0.028, p = 0.03) (indirect effect = 0.0075, SE = 0.0043; 95% CI [0.0006, 0.0178]), but not with other indices of risk-taking. These findings suggest that rejection sensitivity may be an important mechanism underlying the relationship between abuse and risky sexual behavior among substance users. These effects do not extend to other risk behaviors, supporting the notion that risky sex associated with abuse represents a means to interpersonal connection rather than a general tendency toward self-defeating behavior.


How MDMA flows across the USA: Evidence from price data

Siddharth Chandra, Yan-Liang Yu & Vinay Bihani

Global Crime, forthcoming

This study uses wholesale prices of MDMA for 59 cities in the USA published by the National Drug Intelligence Center (NDIC) over the period of 2002-2011 to identify trafficking patterns of MDMA. Price differentials and correlations between pairs of cities are used to infer the presence of a link and the direction of flow of MDMA. The presence of inward and outward links is used to categorise each city as a 'source', 'destination', 'transit', or 'weakly integrated' city. The analysis identified low prices close to the Canadian and Mexican borders, in a number of cities such as Chicago, Miami, New York City, a trio of cities in the Carolinas, and along the West Coast. A number of these cities are linked to large numbers of other cities, indicating hub- or source-like status. The findings generate insights into the status of major US cities in the MDMA trafficking network.


Trends in cannabis use disorders among racial/ethnic population groups in the United States

Li-Tzy Wu, He Zhu & Marvin Swartz

Drug and Alcohol Dependence, August 2016, Pages 181-190

Minority groups generally experience more disparities than whites in behavioral healthcare use. The population of racial/ethnic groups is growing faster than whites. Given increased concerns of cannabis use (CU) and its associations with health conditions, we examined national trends in cannabis use disorder (CUD) among adults aged ?18 by race/ethnicity.

Methods: Data were from the 2005-2013 National Surveys on Drug Use and Health (N = 340,456). We compared CU patterns and the conditional prevalence of CUD among cannabis users by race/ethnicity to understand racial/ethnic variations in CUD.

Results: Approximately 1.5% of adults met criteria for a CUD in the past year. Regardless of survey year, cannabis dependence was more common than cannabis abuse, representing 66% of adults with a CUD. Across racial/ethnic groups, the prevalence of cannabis abuse and dependence remained stable during 2005-2013. In the total adult sample, the odds of weekly CU, monthly CU, and cannabis dependence were greater among blacks, native-Americans, and mixed-race adults than whites. Among cannabis users, the odds of cannabis abuse and dependence were greater among blacks, native-Americans, and Hispanics than whites. Logistic regression controlling for age, sex, education, and survey year indicated an increased trend in monthly CU and weekly CU in the total sample and among past-year cannabis users. Younger age, male sex, and low education were associated with increased odds of cannabis dependence.

Conclusions: The large sample provides robust information that indicates a need for research to monitor CUD and identify culturally appropriate interventions especially for targeting minority populations.


The Influence of Geography and Measurement in Estimating Cigarette Price Responsiveness

Michael Pesko et al.

NBER Working Paper, June 2016

We use data from the 2006-07 and 2010-11 waves of the Tobacco Use Supplement of the Current Population Survey to calculate cigarette price elasticities that compensate for within-state cigarette prices, which includes variation from the local tax environment. We use four state-level cigarette price measures and two sub-state-level cigarette price measures. For the two local price measures, we exploit month specific changes in these two prices in 446 sub-state areas of the United States. We document substantial variation in within-state prices, and we calculate that this variation approximately triples estimates of cigarette price responsiveness compared to using state-level prices. When using local prices, we calculate that a 10% rise in cigarette prices reduces cigarette consumption by a mean of 2.5%, which ranges from a 1.7% reduction at a price level $3 to a 5.6% reduction at a price level of $9. Our results suggest an important role for the local tax environment in studies of cigarette price responsiveness.


Bayesian inference for the distribution of grams of marijuana in a joint

Greg Ridgeway & Beau Kilmer

Drug and Alcohol Dependence, August 2016, Pages 175-180

Background: The average amount of marijuana in a joint is unknown, yet this figure is a critical quantity for creating credible measures of marijuana consumption. It is essential for projecting tax revenues post-legalization, estimating the size of illicit marijuana markets, and learning about how much marijuana users are consuming in order to understand health and behavioral consequences.

Methods: Arrestee Drug Abuse Monitoring data collected between 2000 and 2010 contain relevant information on 10,628 marijuana transactions, joints and loose marijuana purchases, including the city in which the purchase occurred and the price paid for the marijuana. Using the Brown-Silverman drug pricing model to link marijuana price and weight, we are able to infer the distribution of grams of marijuana in a joint and provide a Bayesian posterior distribution for the mean weight of marijuana in a joint.

Results: We estimate that the mean weight of marijuana in a joint is 0.32 g (95% Bayesian posterior interval: 0.30-0.35).

Conclusions: Our estimate of the mean weight of marijuana in a joint is lower than figures commonly used to make estimates of marijuana consumption. These estimates can be incorporated into drug policy discussions to produce better understanding about illicit marijuana markets, the size of potential legalized marijuana markets, and health and behavior outcomes.


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