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Kevin Lewis

April 18, 2017

The Contribution of Drug Overdose to Educational Gradients in Life Expectancy in the United States, 1992-2011
Jessica Ho
Demography, forthcoming


Since the mid-1990s, the United States has witnessed a dramatic rise in drug overdose mortality. Educational gradients in life expectancy widened over the same period, and drug overdose likely plays a role in this widening, particularly for non-Hispanic whites. The contemporary drug epidemic is distinctive in terms of its scope, the nature of the substances involved, and its geographic patterning, which influence how it impacts different education groups. I use vital statistics and National Health Interview Survey data to examine the contribution of drug overdose to educational gradients in life expectancy from 1992-2011. I find that over this period, years of life lost due to drug overdose increased for all education groups and for both males and females. The contribution of drug overdose to educational gradients in life expectancy has increased over time and is greater for non-Hispanic whites than for the population as a whole. Drug overdose accounts for a sizable proportion of the increases in educational gradients in life expectancy, particularly at the prime adult ages (ages 30-60), where it accounts for 25 % to 100 % of the widening in educational gradients between 1992 and 2011. Drug overdose mortality has increased more rapidly for females than for males, leading to a gender convergence. These findings shed light on the processes driving recent changes in educational gradients in life expectancy and suggest that effective measures to address the drug overdose epidemic should take into account its differential burden across education groups.

Placebo Effects of Marketing Labels on Perceived Intoxication and Risky Attitudes and Behaviors
Yann Cornil, Pierre Chandon & Aradhna Krishna
Journal of Consumer Psychology, forthcoming


Why sexual assaults and car accidents are associated with the consumption of alcohol mixed with energy drinks (AMED) is still unclear. In a single study, we show that the label used to describe AMED cocktails can have causal non-pharmacological effects on consumers' perceived intoxication, attitudes, and behaviors. Young men who consumed a cocktail of fruit juice, vodka, and Red Bull felt more intoxicated, took more risks, were more sexually self-confident, but intended to wait longer before driving when the cocktail's label emphasized the presence of the energy drink (a "Vodka-Red Bull cocktail") compared to when it did not (a "Vodka" or "Exotic fruits" cocktail). Speaking to the process underlying these placebo effects, we found no moderation of experience but a strong interaction with expectations: These effects were stronger for people who believe that energy drinks boost alcohol intoxication and who believe that intoxication increases impulsiveness, reduces sexual inhibition, and weakens reflexes. These findings have implications for understanding marketing placebo effects and for the pressing debate on the regulation of the marketing of energy drinks.

The Effects of E-Cigarette Minimum Legal Sale Age Laws on Youth Substance Use
Dhaval Dave, Bo Feng & Michael Pesko
NBER Working Paper, April 2017


We use difference-in-differences models and individual-level data from the national and state Youth Risk Behavior Surveillance System (YRBSS) from 1991 to 2015 to examine the effects of e-cigarette Minimum Legal Sale Age (MLSA) laws on youth cigarette smoking, alcohol consumption, and marijuana use. Our results suggest that these laws increased youth smoking participation by 0.7 to 1.4 percentage points, approximately half of which could be attributed to smoking initiation. We find little evidence of higher cigarette smoking persisting beyond the point at which youth age out of the law. Our initial results also show little effect of the law on youth drinking, binge drinking, and marijuana use. Taken together, our findings suggest a possible unintended effect of e-cigarette MLSA laws - rising cigarette use in the short term while youth are restricted from purchasing e-cigarettes.

Bans on electronic cigarette sales to minors and smoking among high school students
Rahi Abouk & Scott Adams
Journal of Health Economics, July 2017, Pages 17-24


Many states have banned electronic cigarette sales to minors under the rationale that using e-cigarettes leads to smoking traditional combustion cigarettes. Such sales bans would be counterproductive, however, if e-cigarettes and traditional cigarettes are substitutes, as bans might push teenagers back to smoking the more dangerous combustion cigarettes. We provide evidence that these sales bans reduce the incidence of smoking conventional cigarettes among high school seniors. Moreover, we provide evidence suggesting that sales bans reduced e-cigarette usage as well. This evidence suggests that not only are e-cigarettes and smoking regular cigarettes positively related and not substitutes for young people, banning retail sales to minors is an effective policy tool in reducing tobacco use.

Is employment status in adults over 25 years old associated with nonmedical prescription opioid and stimulant use?
Alexander Perlmutter et al.
Social Psychiatry and Psychiatric Epidemiology, March 2017, Pages 291-298

Purpose: Nonmedical use of prescription opioid and stimulants (NMUPO and NMUPS, respectively) has declined in recent years, but remains an important public health problem. Evidence regarding their relationships with employment status remains unclear. We determined the relationship between employment status and NMUPO and NMUPS.

Methods: We analyzed a cross-sectional, nationally representative, weighted sample of 58,486 adults, ages 26 years and older, using combined 2011-2013 data from the National Survey on Drug Use and Health (NSDUH). We fit two crude and two adjusted multivariable logistic regression models to assess the relationship between our two different outcomes of interest: (1) past-year NMUPO and (2) past-year NMUPS, and our exposure of interest: employment status, categorized as (1) full time, (2) part time, (3) unemployed, and (4) not in the workforce. Our adjusted models featured the following covariates: sex, race, age, marital status, and psychological distress, and other nonmedical use.

Results: Prevalence of NMUPO was higher than NMUPS (3.48 vs. 0.72%). Unemployed participants had the highest odds of NMUPO [aOR 1.45, 95% CI (1.15-1.82)], while those not in the workforce had the highest odds of NMUPS [aOR 1.71, 95% CI (1.22-2.37)]. Additionally, part-time and unemployed individuals had increased odds of NMUPS [aORs, 95% CI 1.59 (1.09-2.31) and 1.67 (1.11-2.37) respectively], while those not in the workforce had decreased odds of NMUPO [aOR 0.82, 95% CI (0.68-0.99)] relative to full-time participants.

College-going and Trajectories of Drinking from Adolescence into Adulthood
Robert Crosnoe, Sarah Kendig & Aprile Benner
Journal of Health and Social Behavior, forthcoming


To explore an exception to the association between educational attainment and health, this study unpacked variability in the drinking of U.S. college students by applying life course concepts to analyses of the National Longitudinal Study of Adolescent Health (Add Health). Growth curve models showed that youth who graduated from four-year colleges before turning 25 without later reentering higher education had the highest peaks in drinking after adolescence and the shallowest declines into their 30s. Deviations from this pathway in terms of type, timing, and order of college transitions flattened out drinking trajectories from adolescence into adulthood. Expectations that more alignment between precollege and college social contexts (defined by family backgrounds, high school academic performance, and peer norms) would predict the most problematic drinking trajectories among young four-year college-goers were not supported. Instead, youth who appeared headed for the early four-year college pathway but did not make it there had problematic drinking trajectories.

Symptoms of obsessive-compulsive disorder predict cannabis misuse
Alexander Spradlin, Dakota Mauzay & Carrie Cuttler
Addictive Behaviors, forthcoming

Methods: A large sample of young adult cannabis users (n = 430) completed an online survey containing measures of OCD symptoms, cannabis use, cannabis misuse, and cannabis use motives.

Results: Severity of OCD (as indexed by higher scores on the Obsessive-Compulsive Inventory-Revised) was unrelated to frequency and quantity of cannabis use, but it was significantly, positively related to increased cannabis misuse. These effects persisted after controlling for anxiety, depression, and stress. The specific feature of obsessing was found to consistently predict cannabis misuse. Finally, an indirect effect of severity of OCD on cannabis misuse via coping motives was discovered.

High frequency repetitive transcranial magnetic stimulation of the left dorsolateral prefrontal cortex for methamphetamine use disorders: A randomised clinical trial
Hang Su et al.
Drug and Alcohol Dependence, June 2017, Pages 84-91

Methods: Thirty MA-addicted patients were randomized to receive 5 sessions of 8 min sham or 10 Hz rTMS to the left DLPFC. Subjects rated their craving at baseline, after exposed to MA-associated cues and after rTMS sessions.

Results: Real rTMS over the left DLPFC reduced craving significantly after 5 sessions of rTMS as compared to sham stimulation. Furthermore, real rTMS improved verbal learning and memory and social cognition in MA-addicted patients.

Conclusions: The present study suggests that 10 Hz rTMS of the left DLPFC may reduce craving and have no negative effects on cognitive function in MA-addicted patients, supporting the safety of rTMS in treating MA addiction.

Environmental risks outweigh dopaminergic genetic risks for alcohol use and abuse from adolescence through early adulthood
Rebekah Levine Coley, Jacqueline Sims & Jennifer Carrano
Drug and Alcohol Dependence, June 2017, Pages 106-118

Methods: Multilevel growth models assessed trajectories of alcohol use and intoxication and ordered logistic regressions assessed alcohol use disorder among a sample of 12,437 youth from the nationally representative Add Health study who were followed from mid-adolescence through early adulthood.

Results: Endogenous and exogenous stressful life events and social norms supportive of alcohol use from parents and peers were significant predictors of alcohol use, intoxication, and alcohol use disorder, with consistent patterns across males and females. In contrast, a dopamine-system genetic risk score (GRS) was not associated with alcohol use trajectories nor alcohol use disorder in early adulthood, although weak connections emerged between the GRS and growth trajectories of intoxication, indicating that higher GRS predicted more frequent episodes of intoxication during the transition to adulthood but not during adolescence or later 20s. No evidence of gene-environment interactions emerged.

Geospatial analysis of emergency department visits for targeting community-based responses to the opioid epidemic
Daniel Dworkis et al.
PLoS ONE, March 2017


The opioid epidemic in the United States carries significant morbidity and mortality and requires a coordinated response among emergency providers, outpatient providers, public health departments, and communities. Anecdotally, providers across the spectrum of care at Massachusetts General Hospital (MGH) in Boston, MA have noticed that Charlestown, a community in northeast Boston, has been particularly impacted by the opioid epidemic and needs both emergency and longer-term resources. We hypothesized that geospatial analysis of the home addresses of patients presenting to the MGH emergency department (ED) with opioid-related emergencies might identify "hot spots" of opioid-related healthcare needs within Charlestown that could then be targeted for further investigation and resource deployment. Here, we present a geospatial analysis at the United States census tract level of the home addresses of all patients who presented to the MGH ED for opioid-related emergency visits between 7/1/2012 and 6/30/2015, including 191 visits from 100 addresses in Charlestown, MA. Among the six census tracts that comprise Charlestown, we find a 9.5-fold difference in opioid-related ED visits, with 45% of all opioid-related visits from Charlestown originating in tract 040401. The signal from this census tract remains strong after adjusting for population differences between census tracts, and while this tract is one of the higher utilizing census tracts in Charlestown of the MGH ED for all cause visits, it also has a 2.9-fold higher rate of opioid-related visits than the remainder of Charlestown. Identifying this hot spot of opioid-related emergency needs within Charlestown may help re-distribute existing resources efficiently, empower community and ED-based physicians to advocate for their patients, and serve as a catalyst for partnerships between MGH and local community groups. More broadly, this analysis demonstrates that EDs can use geospatial analysis to address the emergency and longer-term health needs of the communities they are designed to serve.

Impact of Medicaid Expansion on Medicaid-covered Utilization of Buprenorphine for Opioid Use Disorder Treatment
Hefei Wen et al.
Medical Care, April 2017, Pages 336-341

Research Design: We used a quasi experimental difference-in-differences design to compare the pre-post changes in Medicaid-covered buprenorphine prescriptions and buprenorphine spending between the 26 states that implemented Medicaid expansions under the Affordable Care Act in 2014 and those that did not.

Measures: Quarterly Medicaid prescriptions for buprenorphine and spending on buprenorphine from the Centers for Medicare and Medicaid Services Medicaid Drug Utilization files 2011 to 2014.

Results: State implementation of Medicaid expansions in 2014 was associated with a 70% increase (P<0.05) in Medicaid-covered buprenorphine prescriptions and a 50% increase (P<0.05) in buprenorphine spending. Physician prescribing capacity was also associated with increased buprenorphine utilization.

Exploring heterogneity in the impact of smoking bans among early and late adopters
Silda Nikaj, Joshua Miller & John Tauras
Economics Letters, June 2017, Pages 164-167


This paper exploits variation in the timing of smoking bans in bars and restaurants, and examines whether sample selection drove the null results of earlier economic impact studies. An untested hypothesis posits that early adopters could better absorb the shock of bans, but among worse selected late adopters, bans would adversely impact bar and restaurant sales. We are the first U.S. study to use administrative tax records from roughly 28,000 establishments. We find similar adjustment trajectories between late and early adopters. Overall bans do not produce a significant adverse economic impact.

The Impact of Clandestine Methamphetamine Labs on Property Values: Discovery, Decontamination and Stigma
Bern Dealy, Brady Horn & Robert Berrens
Journal of Urban Economics, May 2017, Pages 161-172


While a large literature addresses the societal cost of substance abuse across a number of domains, little is known about the impact of substance abuse on property values. This study uses unique data from Linn County, Oregon and a spatial, difference-in-difference identification strategy to test the impact of the discovery and the subsequent decontamination of clandestine methamphetamine (meth) laboratories (labs) on property values. Results suggest that even though meth labs are typically found in less-desirable neighborhoods with lower home prices, the discovery of a lab causes the price of nearby homes to drop by approximately six and a half percent. Further, the decontamination of homes used as meth labs results in an increase in property values by approximately five percent. Overall, these results suggest that beyond the potential direct benefits of reducing domestic meth production (e.g., reductions in crime, child abuse), disrupting domestic meth production has another important benefit in mitigating negative effects on property values. Also, state laws mandating the decontamination of meth labs and corresponding decontamination programs may yield significant positive net benefits. Finally, the fact that meth lab decontamination does not fully offset the impact of discovery (homes recover about 75%) suggests a potential stigma effect associated with meth lab discovery.

Effects of Posted Point-of-Sale Warnings on Alcohol Consumption During Pregnancy and on Birth Outcomes
Gulcan Cil
Journal of Health Economics, May 2017, Pages 131-155


In 23 states and Washington D.C., alcohol retailers are required by law to post alcohol warning signs (AWS) that warn against the risks of drinking during pregnancy. Using the variation in the adoption of these laws across states and within states over time, I find a statistically significant reduction in prenatal alcohol use associated with AWS. I then use this plausibly exogenous change in drinking behavior to establish a causal link between prenatal alcohol exposure and birth outcomes. I find that AWS laws are associated with decreases in the odds of very low birth weight and very pre-term birth.


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