When They Go High
The Impact of Cannabis Access Laws on Opioid Prescribing
Benjamin McMichael, Lawrence Van Horn & Kip Viscusi
Journal of Health Economics, forthcoming
Abstract:
While recent research has shown that cannabis access laws can reduce the use of prescription opioids, the effect of these laws on opioid use is not well understood for all dimensions of use and for the general United States population. Analyzing a dataset of over 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level, we find that recreational and medical cannabis access laws reduce the number of morphine milligram equivalents prescribed each year by 11.8 and 4.2 percent, respectively. These laws also reduce the total days supply of opioids prescribed, the total number of patients receiving opioids, and the probability a provider prescribes any opioids net of any offsetting effects. Additionally, we find consistent evidence that cannabis access laws have different effects across types of providers, physician specialties, and payers.
E-Cigarettes and Adult Smoking: Evidence from Minnesota
Henry Saffer et al.
NBER Working Paper, December 2019
Abstract:
E-cigarettes use a battery powered heater to turn a liquid containing nicotine into a vapor. The vapor is inhaled by the user and is generally considered to be less harmful than the smoke from combustible cigarettes because the vapor does not contain the toxins that are found in tobacco smoke. Because e-cigarettes provide an experience that is very similar to smoking, they may be effective in helping smokers to quit, and thus the availability of e-cigarettes could increase quit rates. Alternatively, e-cigarettes may provide smokers with a method of bypassing smoking restrictions and prolong the smoking habit. There is very little causal evidence to date on how e-cigarette use impacts smoking cessation among adults. Although there is no federal tax on e-cigarettes, a few states have recently imposed heavy taxes on them. We provide some of the first evidence on how e-cigarette taxes impact adult smokers, exploiting the large tax increase in Minnesota. That state was the first to impose a tax on e-cigarettes by extending the definition of tobacco products to include e-cigarettes. This tax, which is 95% of the wholesale price, provides a plausibly exogenous deterrent to e-cigarette use. We utilize data from the Current Population Survey Tobacco Use Supplements from 1992 to 2015, in conjunction with a synthetic control difference-in-differences approach. We assess how this large tax increase impacted smoking cessation among adult smokers. Estimates suggest that the e-cigarette tax increased adult smoking and reduced smoking cessation in Minnesota, relative to the control group, and imply a cross elasticity of current smoking participation with respect to e-cigarette prices of 0.13. Our results suggest that in the sample period about 32,400 additional adult smokers would have quit smoking in Minnesota in the absence of the tax. If this tax were imposed on a national level about 1.8 million smokers would be deterred from quitting in a ten year period. The taxation of e-cigarettes at the same rate as cigarettes could deter more than 2.75 million smokers nationally from quitting in the same period. The public health benefits of not taxing e-cigarettes, however, must be weighed against effects of this decision on efforts to reduce vaping by youth.
Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis
Atheendar Venkataramani et al.
JAMA Internal Medicine, forthcoming
Design, Setting, and Participants: A county-level difference-in-differences study was conducted among adults aged 18 to 65 years in 112 manufacturing counties located in 30 commuting zones (primarily in the US South and Midwest) with at least 1 operational automotive assembly plant as of 1999. The study analyzed county-level changes from January 1, 1999, to December 31, 2016, in age-adjusted, county-level opioid overdose mortality rates before vs after automotive assembly plant closures in manufacturing counties affected by plant closures compared with changes in manufacturing counties unaffected by plant closures. Data analyses were performed between April 1, 2018, and July 20, 2019.
Results: During the study period, 29 manufacturing counties in 10 commuting zones were exposed to an automotive assembly plant closure, while 83 manufacturing counties in 20 commuting zones remained unexposed. Mean (SD) baseline opioid overdose rates per 100 000 were similar in exposed (0.9 [1.4]) and unexposed (1.0 [2.1]) counties. Automotive assembly plant closures were associated with statistically significant increases in opioid overdose mortality. Five years after a plant closure, mortality rates had increased by 8.6 opioid overdose deaths per 100 000 individuals (95% CI, 2.6-14.6; P = .006) in exposed counties compared with unexposed counties, an 85% increase relative to the mortality rate of 12 deaths per 100 000 observed in unexposed counties at the same time point. In analyses stratified by age, sex, and race/ethnicity, the largest increases in opioid overdose mortality were observed among non-Hispanic white men aged 18 to 34 years (20.1 deaths per 100 000; 95% CI, 8.8-31.3; P = .001) and aged 35 to 65 years (12.8 deaths per 100 000; 95% CI, 5.7-20.0; P = .001). We observed similar patterns of prescription vs illicit drug overdose mortality. Estimates for opioid overdose mortality in nonmanufacturing counties were not statistically significant.
Abandoned by Coal, Swallowed by Opioids?
Gilbert Metcalf & Qitong Wang
NBER Working Paper, December 2019
Abstract:
Opioid addition and mortality skyrocketed over the past decade. A casual look at the geographic incidence of opioid mortality shows sharply higher mortality rates in the Appalachian region, especially in coal-mining areas. This has led observers to make a link that was characterized by one newspaper as “abandoned by coal, swallowed by opioids.” We test that theory using restricted death data and mine level coal production data. Specifically, we examine whether higher reliance on coal mining in a county’s economy leads to higher or lower opioid mortality. We find a positive relationship between the share of coal miners among total local labor force and county-level opioid mortality rates. This contradicts the “abandoned by coal, swallowed by opioids” story. Rather our results suggest that the higher rates of injury in underground coal mining (in particular) lead to greater amounts of opioid consumption and mortality. An implication is that the decline in coal mining in the United States may have a positive spillover in the form of reduced mortality from opioid use.
Trends in alcohol and marijuana detected in homicide victims in 9 US states: 2004–2016
Oybek Nazarov & Guohua Li
Injury Epidemiology, January 2020
Methods: We analyzed toxicological testing data for homicide victims (n = 12,638) from the 2004–2016 National Violent Death Reporting System in 9 US states (Colorado, Georgia, Massachusetts, New Jersey, Oregon, Rhode Island, South Carolina, Virginia, and Wisconsin). We used the Cochran-Armitage test for trend to assess the statistical significance of changes in the prevalence of alcohol and marijuana detected in these homicide victims during the study period.
Results: Overall, 37.5% of the homicide victims tested positive for alcohol, 31.0% positive for marijuana, and 11.4% positive for both substances. During the study period, the prevalence of marijuana increased from 22.3% (95% confidence interval [CI] = 19.6, 25.0) in 2004 to 42.1% (95% CI = 39.2, 44.9) in 2016 (Z = -15.7; P < .001) while the prevalence of alcohol declined slightly (Z = 1.5; P = 0.143). Marked increases in the prevalence of marijuana were observed in both sexes and across age and racial groups.
Sadness, but not all negative emotions, heightens addictive substance use
Charles Dorison et al.
Proceedings of the National Academy of Sciences, 14 January 2020, Pages 943-949
Abstract:
Do negative feelings in general trigger addictive behavior, or do specific emotions play a stronger role? Testing these alternative accounts of emotion and decision making, we drew on the Appraisal Tendency Framework to predict that sadness, specifically, rather than negative mood, generally, would 1) increase craving, impatience, and actual addictive substance use and 2) do so through mechanisms selectively heightened by sadness. Using a nationally representative, longitudinal survey, study 1 (n = 10,685) revealed that sadness, but not other negative emotions (i.e., fear, anger, shame), reliably predicted current smoking as well as relapsing 20 years later. Study 2 (n = 425) used an experimental design, and found further support for emotion specificity: Sadness, but not disgust, increased self-reported craving relative to a neutral state. Studies 3 and 4 (n = 918) introduced choice behavior as outcome variables, revealing that sadness causally increased impatience for cigarette puffs. Moreover, study 4 revealed that the effect of sadness on impatience was more fully explained by concomitant appraisals of self-focus, which are specific to sadness, than by concomitant appraisals of negative valence, which are general to all negative emotions. Importantly, study 4 also examined the topography of actual smoking behavior, finding that experimentally induced sadness (as compared to neutral emotion) causally increased the volume and duration of cigarette puffs inhaled. Together, the present studies provide support for a more nuanced model regarding the effects of emotion on tobacco use, in particular, as well as on addictive behavior, in general.
Alcohol Advertising and Violence
Pamela Trangenstein et al.
American Journal of Preventive Medicine, forthcoming
Introduction: Numerous studies have found associations between alcohol outlet density and violence, but it is unknown whether alcohol advertisements visible outside outlets are also associated with violent crime. Baltimore City, MD enacted restrictions on retail alcohol establishment advertising practices as of June 5, 2017. This study examines the association between alcohol advertisements visible outside off-premise alcohol outlets and violent crime before this restriction.
Methods: Outlet observations (n=683) were conducted in summer 2015, and violent crime data (n=24,085) were from June 5, 2015, through June 4, 2017. The number of violent crimes per square mile within 1,000 feet of outlets was summed using kernel density estimation. In 2018–2019, authors used mixed models with a Simes–Benjamini–Hochberg correction for multiple testing.
Results: Roughly half (47%, n=267) of the outlets with complete data (n=572) had alcohol advertisements visible from the exterior. Outlets with alcohol advertisements had 15% more violent crimes per square mile within 1,000 feet (eβ=1.15, 95% CI=1.07, 1.25, q<0.001) after adjusting for neighborhood context. All associations between alcohol advertisements and specific types of violent crime were significant, with the association strongest for homicides (eβ=1.28, 95% CI=1.13, 1.46, q<0.001). There was no association between cigarette advertisements and violent crime (eB=1.08, 95% CI=0.92, 1.26, q=0.43).
An Economic Analysis of Business Drinking: Evidence from a Lab-in-the-field Experiment
Jianxin Wang & Daniel Houser
George Mason University Working Paper, November 2019
Abstract:
Alcohol consumption is an important component of business negotiations across many cultures, yet this behavior remains unmodeled and its potential implications untested. This paper is a step towards filling that gap. We develop a theory that combines guilt-aversion with a canonical alcohol myopia framework. Our GAAM (guilt aversion and alcohol myopia) model predicts that intoxication increases promise-making but has no effect on promise-breaking. We test these predictions using a prisoner’s dilemma game with pre-play communication in a lab-in-the-field experiment. Among males, we find behavior consistent with predictions: intoxication promotes promise-making behavior but does not impact the rate at which promises are trusted or broken. Consequently, intoxication increases communication efficiency. We do not observe intoxication to impact female promise-making, trusting, or promise-breaking behaviors. This is consistent with previous empirical findings that females are substantially less sensitive than males to alcohol-induced myopia.
Economic Policy Uncertainty and Self-Control: Evidence from Unhealthy Choices
Ivalina Kalcheva, Ping McLemore & Richard Sias
Federal Reserve Working Paper, December 2019
Abstract:
We hypothesize that greater economic policy uncertainty (EPU) leads to increases in unhealthy behaviors by lowering individuals’ impulse control. Based on 6.1 million interviews over 22 years, our analysis reveals a positive relation between EPU and the propensity to make poor lifestyle choices including higher rates of alcohol consumption, a larger number of drinks consumed, and greater binge drinking. EPU has long-lasting effects on drinking behavior, consistent with habit formation. Moreover the relation is stronger for younger individuals whose habits are more malleable. We find similar results when using smoking rates to measure unhealthy choices.
Changes in Medicaid Acceptance by Substance Abuse Treatment Facilities After Implementation of Federal Parity
Kimberley Geissler & Elizabeth Evans
Medical Care, February 2020, Pages 101–107
Research Design: Observational study using an interrupted time series design.
Subjects: 2002–2013 data from the National Survey of Substance Abuse Treatment Services (N-SSATS) for all SUD treatment facilities was combined with state-level characteristics.
Results: Implementation of MHPAEA was associated with a 4.6 percentage point increase in the probability of an SUD treatment facility accepting Medicaid (P<0.001), independent of facility and state characteristics, time trends, and key characteristics of state Medicaid programs.