Cost of Cigarette Smoking‒Attributable Productivity Losses, U.S., 2018

Correlation Among Neighborhood-Level Measures of the Tobacco Retail Environment

INTRODUCTION

Tobacco retailer density and distance to tobacco retailers are understood to influence tobacco-related behaviors; however, there is no general agreement on how to best characterize or measure the tobacco retail environment (TRE). In this data-driven analysis, we examine similarities among neighborhood-level measures of the TRE and assess how the geographic resolution of the neighborhood units may affect them.

AIMS AND METHODS

We used locations of likely tobacco retailers in the United States to calculate multiple retailer count, density, and distance measures. Measures were calculated at the Census block group, tract, and county (including county equivalents) levels of geographic aggregation. Spearman's correlation was used to evaluate the similarity among the TRE measures.

RESULTS

At the block group and tract level, correlation among all TRE measures ranged from slightly negative (ρ = -0.03) to nearly perfect (ρ = 0.99). At both levels of aggregation, distance-based TRE measures were highly correlated (ρ > 0.76). At the block group level, the simple count of retailers was highly correlated with the density measures (ρ > 0.83), and at the tract level, simple count was moderately to highly correlated with the density measures (ρ > 0.5). Findings were generally similar at the county level; a notable deviation was that retailers per person were negatively correlated with all other TRE measures (range from ρ = -0.08 to ρ = -0.32).

CONCLUSIONS

Some common measures were not correlated, suggesting they capture different aspects of the TRE; similarity among the various measures also varied by level of geographic aggregation.

IMPLICATIONS

Because the TRE shapes people's tobacco-related behaviors, using appropriate measures to characterize it at a neighborhood level is paramount. Our work highlights both the similarities and differences among a set of common measures, thereby suggesting the measures may be capturing different aspects of the overall retail environment. Our findings regarding geographic level of aggregation underscore the importance of neighborhood definition in any TRE analysis.

Tobacco Smoking in Early Adulthood and Labor Market Performance: The Cardiovascular Risk in Young Finns Study

INTRODUCTION

Tobacco smoking has been associated with reduced success in the labor market, potentially due to its negative impact on labor productivity, especially in physically demanding jobs, as it affects physical fitness and performance adversely.

METHODS

This prospective study used data from the Cardiovascular Risk in Young Finns Study survey, linked to register information on labor market outcomes and education attainment, to examine the association between tobacco smoking and long-term labor market outcomes (earnings and employment, N = 1953). Smoking levels were determined by cigarette pack-years in 2001, as reported in the survey, whereas annual earnings and employment status were tracked from 2001 to 2019.

RESULTS

A one-unit increase in pack-year of smoking was associated with a 1.8% decrease in earnings (95% confidence interval [CI]: -2.6% to -0.9%) and a 0.5% reduction in years employed (95% CI: -0.6% to -0.3%). This association was pronounced among participants with lower education levels. The earnings difference was evident among younger cohorts, whereas a negative correlation with employment was observed most strongly in older cohorts among individuals with lower education.

CONCLUSIONS

Our findings suggest that smoking had a negative effect on earnings among the younger generation, particularly among the less well-educated. The finding of greater impacts on years of employment among the older age group, particularly among groups with low education levels, is consistent with the delayed onset of most health impacts, which may particularly affect productivity in physically demanding jobs that are more common among people with less education.

IMPLICATIONS

Adverse consequences of smoking include reduced earnings and labor market participation, particularly among less well-educated groups. Tobacco control advocates should draw attention to these consequences in arguing for effective measures to reduce smoking initiation and increase cessation in order to achieve socially optimal outcomes.

Social Costs of Smoking in the Czech Republic

OBJECTIVES

Smoking is an important risk factor leading to many diseases, which brings substantial healthcare costs as well as indirect costs due to decreased productivity. This article aims to quantify the social costs of smoking in the Czech Republic in 2019.

METHODS

The prevalence-based, cost-of-illness approach is used, which assesses the costs as the sum of direct (healthcare) costs and indirect costs (productivity losses due to mortality and morbidity). The costs of healthcare utilization and pharmacotherapy in direct costs, and the costs of absenteeism, presenteeism, and premature mortality in indirect costs, are included.

RESULTS

Total costs of smoking in the Czech Republic in 2019 are estimated as 2110.6 million EUR (0.94% of GDP). Direct costs amounted to 537.0 million EUR (2.9% of health expenditures in 2019) and indirect costs were 1573.6 million EUR, mainly driven by the costs of premature mortality (1062.5 million EUR).

CONCLUSIONS

Despite the declining trend in the prevalence of smoking in the Czech Republic, the associated costs are considerable. Investments into strategies to reduce smoking continue to be needed.

Unlocking the power of tobacco taxation to mitigate the social costs of smoking in Mexico: a microsimulation model

Despite being the most cost-effective tobacco control policy, tobacco taxation is the least implemented component of the World Health Organization MPOWER package to reduce smoking worldwide. In Mexico, both smoking prevalence and taxation have remained stable for more than a decade. This study aims to provide evidence about the potential effects of taxation to reduce the burden of tobacco-related diseases and the main attributable social costs in Mexico, including informal (unpaid) care costs, which are frequently ignored. We employ a first-order Monte Carlo microsimulation model that follows hypothetical population cohorts considering the risks of an adverse health event and death. First, we estimate tobacco-attributable morbidity and mortality, direct medical costs and indirect costs, such as labour productivity losses and informal care costs. Then, we assess the potential effects of a 50% cigarette price increase through taxation and two alternative scenarios of 25% and 75%. The inputs come from several sources, including national surveys and vital statistics. Each year, 63 000 premature deaths and 427 000 disease events are attributable to tobacco in Mexico, while social costs amount to MX$194.6 billion (US$8.5)-MX$116.2 (US$5.1) direct medical costs and MX$78.5 (US$3.4) indirect costs-representing 0.8% of gross domestic product. Current tobacco tax revenue barely covers 23.3% of these costs. Increasing cigarette prices through taxation by 50% could reduce premature deaths by 49 000 over the next decade, while direct and indirect costs averted would amount to MX$87.9 billion (US$3.8) and MX$67.6 billion (US$2.9), respectively. The benefits would far outweigh any potential loss even in a pessimistic scenario of increased illicit trade. Tobacco use imposes high social costs on the Mexican population, but tobacco taxation is a win-win policy for both gaining population health and reducing tobacco societal costs.

Isradipine augmentation of virtual reality cue exposure therapy for tobacco craving: a triple-blind randomized controlled trial

Preclinical research with rodents suggests that the L-type calcium channel blocker isradipine can enhance long-term extinction of conditioned place preference for addictive substances when it is administered in conjunction with extinction training. Although isradipine alone, which is FDA-approved for hypertension, has not shown a direct effect on craving in human drug users, its potential to augment behavioral treatments designed to reduce craving remains unknown. We conducted a triple-blind, randomized placebo-controlled pilot clinical trial of isradipine combined with a novel virtual reality cue exposure therapy (VR-CET) approach with multimodal cues that targeted craving. After 24 hours of abstinence, 78 adults with an ongoing history of daily cigarette use received isradipine (n = 40) or placebo (n = 38) and reported craving levels after each of 10 trials of VR-CET. Consistent with pre-registered hypotheses, the isradipine group had significantly lower mean craving across cue exposure trials at the medication-free 24-hour follow-up (d = -0.42, p = 0.046). There were no serious adverse events; however, side effects such as headache and dizziness occurred more frequently in the isradipine group. The findings of the current study support follow-up clinical trials that specifically test the efficacy of isradipine-augmented VR-CET for reducing smoking relapse rates after an initial quit attempt. clinicaltrials.gov: NCT03083353.

Productivity costs of lifelong smoking-the Northern Finland Birth Cohort 1966 study

BACKGROUND

Smoking is one of the leading causes of impaired health and mortality. Loss of paid and unpaid work and replacements due to morbidity and mortality result in productivity costs. Our aim was to investigate the productivity costs of lifelong smoking trajectories and cumulative exposure using advanced human capital method (HCM) and friction cost method (FCM).

METHODS

Within the Northern Finland Birth Cohort 1966 (NFBC1966), 10 650 persons were followed from antenatal period to age 55 years. The life course of smoking behaviour was assessed with trajectory modelling and cumulative exposure with pack-years. Productivity costs were estimated with advanced HCM and FCM models by using detailed, national register-based data on care, disability, mortality, education, taxation, occupation and labour market. A two-part regression model was used to predict productivity costs associated with lifelong smoking and cumulative exposure.

RESULTS

Of the six distinct smoking trajectories, lifetime smokers had the highest productivity costs followed by late starters, late adult quitters, young adult quitters and youth smokers. Never-smokers had the lowest productivity costs. The higher the number of pack-years, the higher the productivity costs. Uniform patterns were found in both men and women and when estimated with HCM and FCM. The findings were independent of other health behaviours.

CONCLUSIONS

Cumulative exposure to smoking is more crucial to productivity costs than starting or ending age of smoking. This suggests that the harmful effects of smoking depend on dose and duration of smoking and are irrespective of age when smoking occurred.

Analysis of the direct economic impact of smoking-related hospitalizations in Italy

INTRODUCTION

Tobacco-related diseases have a substantial economic impact in terms of medical expenses, loss of productivity, and premature death. Tobacco use is estimated to be responsible for more than 90000 deaths each year in Italy. We aimed to evaluate the annual direct economic impact on the National Health System of hospitalizations attributable to tobacco smoking in Italy.

METHODS

We analyzed data from all the hospitalizations of patients aged ≥30 years that occurred in Italy for 12 selected tobacco-related diseases, during 2018. These diseases included oropharyngeal cancer, esophageal cancer, gastric cancer, lung cancer, pancreatic cancer, bladder cancer, laryngeal cancer, ischemic heart disease, stroke, diseases of arteries, arterioles, and capillaries, pneumonia and influenza, and chronic obstructive pulmonary disease. We obtained information on 984322 hospital discharge records, including each hospitalization's direct costs. Using relative risk estimates from the scientific literature, we computed the population attributable fraction for various tobacco-related diseases to estimate the economic impact attributable to tobacco smoking.

RESULTS

One-third of all hospitalizations occurred in 2018 in Italy among people aged ≥30 years for 12 tobacco-related diseases were found to be attributable to smoking, accounting for a total cost of €1.64 billion. Among the diseases considered, those with the highest expenditures attributable to tobacco smoking were ischemic heart disease, cerebrovascular disease, and lung cancer, accounting for €556 million, €290 million, and €229 million, respectively.

CONCLUSIONS

Tobacco has a substantial economic impact in Italy, accounting for around 6% of the total cost of hospitalizations in 2018. This figure is expected to be largely underestimated due to several conservative assumptions adopted in the statistical analyses. It is imperative to prioritize comprehensive tobacco control measures to counteract the huge healthcare costs due to tobacco smoking.

Behavioral and Pharmacokinetic Assessment of Nicotine e-Cigarette Inhalation in Female Rats

INTRODUCTION

Nicotine and tobacco use remain high both globally and in the United States, contributing to large health care expenditures. With a rise in e-cigarette use, it is important to have clinically relevant models of inhaled nicotine exposure.

AIMS AND METHODS

This study aims to extend prior preclinical nicotine inhalation animal data to females and provide both behavior and serum pharmacokinetics. We tested two inhalation doses of nicotine (24 mg/mL and 59 mg/ mL) and compared these to injected doses (0.4 mg/kg and 1 mg/kg). In addition, we assessed locomotor behavior after the same doses. Blood was collected at 10- and 120-minutes post-administration. We assessed nicotine and cotinine serum concentrations by LC-MS/MS.

RESULTS

Showed that while nicotine serum concentrations for the respective high and low-dose administrations were similar between both routes of administration, the route had differential effects on locomotor behavior. Inhaled nicotine showed a dose-dependent decrease in locomotor activity while injected doses showed the opposite trend.

CONCLUSIONS

Our results indicate that the route of administration is an important factor when establishing preclinical models of nicotine exposures. Given that the overall use of e-cigarettes in vulnerable populations is on the rise, our study provides important behavioral and pharmacokinetic information to advance our currently limited understanding of the effects of nicotine vapor exposure.

IMPLICATIONS

This study highlights behavioral differences between different routes of administration of similar doses of nicotine. Using a low and high dose of nicotine, we found that nicotine serum concentrations were similar between the different routes of administration. Our results indicate that different routes of administration have opposing effects on locomotor activity. These findings provide important implications for future behavioral models.

Evaluation of physical and mental health conditions related to employees' absenteeism

Background

Employees' health conditions are issues for not only employees themselves but also companies and society to keep medical costs low and productivity high.

Data and methods

In this analysis, 15,574 observations from 2,319 employees at four operational sites of a large corporation were used. The dataset contained physical and mental health conditions obtained from annual mandatory medical checkups, the Brief Job Stress Questionnaire (BJSQ), and work record information. Health and other factors related to long-term absenteeism (over three days in a quarter) were analyzed. Data were collected between February 2021 and January 2022, and we converted into quarterly observations. A logit (logistic regression) model was used in the analysis.

Results

Age and gender were identified as important basic characteristics. The estimates for these variables were positive and negative and significant at the 1% level. Among the variables obtained from the medical checkups, the estimates for diastolic blood pressure, HbA1c, anamnesis, heart disease history, smoking, increased weight, and frequency of alcohol consumption were positive and significant at the 1% level, further those for taking antihypertensive medications and kidney disease history were positive and significant at the 5% level. In contrast, the estimates for systolic blood pressure and amount of alcohol consumption were negative and significant at the 1% level. The estimate for taking antihyperglycemic medications and health guidelines were negative and significant at the 5% level. Among the variables obtained from the BJSQ, the estimates for amount of work felt, fatigue and support from family and friends were positive and significant at the 1%, and the estimate for irritation was positive and significant at the 5% level. The estimates for controlling job and physical complaints were negative and significant at the 1% level, and those for usage of employee's ability to work and suitability of the work were negative and significant at the 5% level. As all four operational sites were located in the northeastern region of Japan (cold and snowy in winter), the seasonal effects were significant at the 1% level. The effect of year was also significant and significant differences were observed among the sites at the 1% level.

Conclusion

Some physical and mental health conditions were strongly associated with long-term absenteeism. By improving these conditions, corporations could reduce the number of employee absence days. As absenteeism was costly for corporations due to replacement employees and their training costs to maintain operations, employers must be concerned about rising healthcare (direct and indirect) costs and implement investments to improve employees' health conditions.

Limitations

This study's results were based on only one corporation and the dataset was observatory. The employees were primarily operators working inside the building and most of them are healthy. Therefore, the sample selection biases might exist, and the results cannot be generalized to other types of jobs, working conditions, or companies. As medical checkups and the BJSQ are mandatory for most companies in Japan, the framework of this study can be applied to other companies. Although we used the BJSQ results, better mental measures might exist. Similar analyses for different corporations are necessary.

A scoping review of smoking cessation pharmacogenetic studies to advance future research across racial, ethnic, and ancestral populations

Abstinence rates among smokers attempting to quit remain low despite the wide availability and accessibility of pharmacological smoking cessation treatments. In addition, the prevalence of cessation attempts and abstinence differs by individual-level social factors such as race and ethnicity. Clinical treatment of nicotine dependence also continues to be challenged by individual-level variability in effectiveness to promote abstinence. The use of tailored smoking cessation strategies that incorporate information on individual-level social and genetic factors hold promise, although additional pharmacogenomic knowledge is still needed. In particular, genetic variants associated with pharmacological responses to smoking cessation treatment have generally been conducted in populations with participants that self-identify as White race or who are determined to be of European genetic ancestry. These results may not adequately capture the variability across all smokers as a result of understudied differences in allele frequencies across genetic ancestry populations. This suggests that much of the current pharmacogenetic study results for smoking cessation may not apply to all populations. Therefore, clinical application of pharmacogenetic results may exacerbate health inequities by racial and ethnic groups. This scoping review examines the extent to which racial, ethnic, and ancestral groups that experience differences in smoking rates and smoking cessation are represented in the existing body of published pharmacogenetic studies of smoking cessation. We will summarize results by race, ethnicity, and ancestry across pharmacological treatments and study designs. We will also explore current opportunities and challenges in conducting pharmacogenomic research on smoking cessation that encourages greater participant diversity, including practical barriers to clinical utilization of pharmacological smoking cessation treatment and clinical implementation of pharmacogenetic knowledge.

US State Policy Contexts and Population Health

Policy Points This Perspective connects the dots between the polarization in US states' policy contexts and the divergence in population health across states. Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties. Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

Economic loss attributable to cigarette smoking in the USA: an economic modelling study

BACKGROUND

Despite large geographical disparities in the prevalence of cigarette smoking across the USA, there is a paucity of state-level estimates of economic loss attributable to smoking to inform tobacco control policies at the national and state levels. We aimed to estimate the state-level economic loss attributable to cigarette smoking in the USA.

METHODS

In this economic modelling study, we used a dynamic macroeconomic model of personal income per capita at the state level. Based on publicly available data on state-level income, its determinants, and smoking status for 2011-20, we first estimated the elasticity of personal income per capita with respect to the prevalence of non-smoking adults (aged ≥18 years) in the USA using a mixed-effects, generalised linear, dynamic panel data model. We used the estimated elasticity to measure the state-specific, annual, avoidable economic loss attributable to cigarette smoking in 2020 under the counterfactual 5% prevalence of cigarette smoking. We then estimated the state-specific cumulative economic loss attributable to cigarette smoking in 2020 using the coefficient of lagged income in the dynamic model. National estimates on economic loss attributable to cigarette smoking were obtained by summing state-specific estimates.

FINDINGS

In the mixed-effects model, the elasticity of personal income per capita with respect to the prevalence of non-smoking adults was 0·143 (p=0·063). The estimated annual income loss per capita in 2020 ranged from US$331 in Utah to $1674 in Kentucky. The state mean population-weighted loss per capita was $1100. The annual combined loss of income and unpaid household production at the national level was $436·7 billion (equivalent to 2·1% of US gross domestic product [GDP] in 2020). The cumulative loss of income and unpaid household production was $864·5 billion (equivalent to 4·3% of US GDP in 2020).

INTERPRETATION

Smoking causes substantial economic loss in the USA. Tobacco control efforts that lower the prevalence of smoking equitably can contribute considerably to improved macroeconomic performance in the short and long term by reducing health expenditures and avoiding productivity losses.

FUNDING

American Cancer Society.