American Journal of Preventive Medicine

BackgroundIf access to Medicaid improves health outcomes, it may also result in lower long-term spending, however the association between Medicaid expansion and Medicare spending is unknown. In this analysis we sought to investigate the association between Medicaid expansion and per capita Medicare spending at the county level. MethodsThis is an observational analysis of all U.S. counties in the ten years from 2010 to 2019. We used a difference-in-difference event study to investigate the difference in per capita Medicare spending between counties in states that expanded Medicaid and counties in states that did not expand Medicaid. The exposure was treatment year, which characterized whether a county was in an expansion state and when expansion occurred. In non-expansion counties, treatment year was assigned 0 for all observations. In expansion counties, treatment year ranged from -3 to +6, with treatment year 1 corresponding to the first full year of expansion. The primary outcome was fee-for-service Medicare spending per capita in each county. A secondary analysis investigated subcategories of per capita spending including inpatient, outpatient, skilled nursing care, inpatient rehabilitation, home health, and hospice care. ResultsWe analyzed 1,648 expansion and 1,494 non-expansion counties, with ten observations per county, one for each year between 2010 and 2019. In the adjusted event study analysis, the difference between expansion and non-expansion counties in expansion year 5 compared to pre-expansion was -200 [95% Confidence Interval (CI): -406, 6] dollars. In the subcategory analysis, the difference in inpatient care, skilled nursing care, outpatient care, and home health spending were -46 [95% CI: -103, 12], -92 [95% CI: -194, 11], 57 [95% CI: -67, 181], and 55 [95% CI: -17, 126] dollars per capita respectively. ConclusionsMedicaid expansion is not consistently significantly associated with lower Medicare spending compared to pre-expansion. However, observed trends towards lower spending and cost-shifting from inpatient to outpatient settings in expansion counties warrant additional investigation.

Overdose prevention health centers (OPHCs), also known as overdose prevention centers or safe injection facilities (SIFs), are an evidence-based strategy for people to use drugs in an environment monitored by health care professionals with access to drug use education, sterile supplies, and referral infrastructure to access higher levels of medical and behavioral health resources. Though still illegal under federal law throughout the United States, many legal or quasi-legal (including some in the United States) have operated since the 1980s. Using CDC overdose deaths and United States Census Bureau population data, we estimate 1,325 deaths could have been averted between 2020 and June 2025 if 1 out of 400 injections had taken place at an OPHC. At this rate, 26 HIV transmissions and 5,723 Hepatitis C Virus transmissions would have been averted. Over $1.8 billion in discounted lifetime costs to treat those infections could have been saved. This data supports OPHCs as one viable public health intervention to avert deaths and avoid infections. Furthermore, a web application was created to assist users explore this analysis, data visualizations, and even alter model assumptions, including variables like what percent of injections occur at an OPHC.

BackgroundSince the 2025 Presidential Inauguration, the Trump Administration has terminated billions of dollars in federal funding for science; however, the impacts of these grant terminations on the mental health and substance use fields have not yet been examined. We thus aimed to quantify and map the costs associated with federally funded mental health- and substance use-related grants that have been prematurely terminated. MethodsWe used a comprehensive dataset of grants terminated by the National Institutes of Health (NIH), National Science Foundation (NSF), and Substance Abuse and Mental Health Services Administration (SAMHSA) compiled from multiple sources. After identifying terminated mental health- and substance use-related grants from this database via a two-step screening process, we quantified their number and associated lost funding for each congressional district, which we visualized using a series of maps to examine trends and regional variations. OutcomesWe identified 474 mental health- and/or substance use-related grants that were terminated by the NIH, NSF, or SAMHSA from February 28, 2025, through April 11, 2025, totaling $2,098,731,548 in lost funds. Congressional districts corresponding to urban centers with large academic and research institutions (e.g., New York City, Boston) experienced the most pronounced losses from NIH and NSF grants, whereas districts located throughout the Mid-Atlantic, Midwest, Southeast, and Southwest were the hardest hit by the termination of SAMHSA block grants (i.e., those used to pay for community mental health and substance use services). InterpretationAgainst a backdrop of ongoing and intersecting mental health and substance use crises, the Trump Administration has slashed research dollars on these topics, creating a chilling effect on the field. Such cuts are likely to destabilize existing mental health and substance use services and exacerbate inequities between and within U.S. states, ultimately intensifying the challenges faced by local communities. FundingNone to report.

BACKGROUNDHealthcare is a major contributor to global greenhouse gas emissions. Colorectal cancer (CRC) screening is one of the most widely used healthcare services in the US, indicated for approximately 134 million adults. Recommended screening options include fecal immunochemical tests (FITs) every year, CT colonographies (CTCs) every 5 years, or colonoscopies every 10 years. We compared the environmental impacts of these tests and identified opportunities for impact reduction. METHODSWe conducted a comparative life cycle assessment of three CRC screening strategies at the University of California, San Francisco. We performed on site audits to document the materials and energy used for each screening test. We used the ReCiPe 2016 method to estimate the environmental impacts of these procedures, measured by global warming potential (GWP) and damage to human health. We estimated the 10-year cumulative impacts of each screening strategy using a Markov reward model. We accounted for model uncertainty using hierarchical Monte Carlo simulations. FINDINGSFIT-based screening had the lowest environmental impacts, with a roughly 20% margin of superiority over colonoscopies, and this finding was robust in sensitivity analyses. Across tests, the biggest cause of environmental harm was car-based transportation of patients and staff. Prioritizing FITs over screening colonoscopies in the US could enhance population health by roughly 5.2 million disability adjusted life years per decade. Transitioning to electric vehicles could reduce the GWP of all screening tests by 15-20%. INTERPRETATIONGiven the similar efficacy and safety of these tests, payors should prioritize FITs for low-risk patients. Government initiatives to decarbonize transportation, incentivize telehealth, and mandate environmental product declarations will help reduce the environmental impacts of healthcare more generally. Our results call for a closer look at resource-intensive preventative health strategies, which could result in more harm than good if applied to a low-risk population. FUNDINGNIH, UCSF

BackgroundCannabinoid hyperemesis syndrome (CHS) is characterized by episodes of severe nausea, vomiting, and abdominal pain among those with heavy cannabis use. We estimated differences between those reporting CHS symptoms and other daily and less frequent cannabis users on drug use, psychiatric problems, other health problems, antisocial behavior, and personality. MethodsThe National Firearms, Alcohol, Cannabis, and Suicide survey was administered to 7034 US adults in 2025. Survey items assessed substance use, common psychiatric symptoms, personality traits, and symptoms of CHS. ResultsThose with CHS symptoms reported the highest rates and greatest variety of drug use compared to others who used cannabis. Those with CHS symptoms reported higher rates of other drug use than those who used cannabis daily without CHS symptoms across a variety of drug classes, including opioids, hallucinogens, and sedatives, higher rates of drug overdoses, and greater use of all drug classes than those with less-than-daily cannabis use. Those with CHS symptoms also reported more depression, anxiety, sleep problems, chronic pain, antisocial behavior, intimate partner violence, and disinhibited personality traits than those who used daily (mean d = 0.58) and less frequently (mean d = 0.69) and those with no cannabis use in the past 12 months (mean d = 0.99). ConclusionsThose with CHS symptoms exhibit a variety of psychological and behavioral problems including higher rates of other drug use, psychiatric symptoms, antisocial behavior, and dysfunctional personality traits. Results highlight the importance of understanding and addressing the broader psychosocial challenges faced by people experiencing CHS symptoms. Highlights O_LICHS symptoms are linked to greater polysubstance use and overdose risk C_LIO_LICHS symptoms are associated with depression, anxiety, sleep, and pain problems C_LIO_LICHS tied to antisocial behavior and intimate partner violence C_LIO_LICHS shows disinhibited personality traits and low well-being C_LIO_LINational survey identifies high-risk psychosocial CHS profile C_LI

ObjectiveSeveral U.S. states have recently enacted excise taxes to curb prescription opioid use and other states are considering similar measures. We assessed the effects of increasing out-of-pocket costs (OPC) on new and recurring opioid fills. MethodsWe conducted a retrospective cohort study of opioid-naive individuals presenting with acute back pain using data from a nationwide claims repository. We estimated the effect of OPC on the initiation of opioid treatment in logistic regressions, controlling for socio-demographics, medical history, healthcare utilization, insurance type, and region. With the same covariates plus morphine milligram equivalents and days supplied, we estimated the effect of OPC on the number of opioid fills in negative binomial regressions. We report the price elasticity of demand (PED) for prescription opioids, defined as the percentage change in outcome resulting from a two-fold increase in OPC. ResultsOf 25,531 adults diagnosed with acute back pain in Q1 of 2018, 2,451 (9.6%) filled at least one opioid prescription. In multivariable regression, the association between OPC and initiating opioid treatment was not significant (PED= -1.9%; 95% CI: -5.5%, 1.7%). However, by region, the PED was -10.3% (95% CI: -18.1%, -2.4%) in the coastal states and 1.6% (95% CI: -2.5%, 5.7%) in the central-southern states. The PED for the number of prescription fills was -3.7% (95% CI: -7.3%, -0.1%), which also differed by region. In the coastal states, the PED was -15.2% (95% CI: -24.7%, -5.7%) and in the central-southern states -1.5% (95% CI: -5.4%, 2.4%). ConclusionsOpioid fills were price sensitive in the coastal states but not in the central-southern states. Policies that would increase OPC might have a restraining effect on opioid consumption in parts, but not all of the U.S.

IntroductionIn the US, cardiovascular diseases (CVD) are the leading cause of death and disability. Cost-related non-adherence (CRMN) can have serious consequences and worsen CVD outcomes. We examined the relationship between CVD risk factors and CRMN among US adults. MethodsCDCs 2019-2021 National Health Interview Survey (NHIS) data was used to examine CRMN among adults, categorized into three groups based on reported risk factors. We used chi-square tests, logistic regression to determine factors associated with CRMN. ResultsAmong 49,464 participants, young, unmarried individuals, females, less educated, and participants from South had higher CRMN than older, married individuals, males, and those with higher education residing in the other regions. Current smokers and those with more CVD risk factors also had a higher CRMN than former smokers and never-smokers. Conversely, those aged 65 or older, with high-income, and excellent self-rated health had lower CRMN than younger participants, low-income families, and those with poor self-health. Public insurance and Medicaid participants had lower CRMN than uninsured (OR 0.13, 95% CI, 0.04-0.45, and OR 0.24, 95% CI, 0.15-0.36). Stratified regression analysis by disease status, i.e., diabetes, hypertension, and hyperlipidemia, revealed participants with high-income had lower odds of CRMN (OR 0.38, 95% CI 0.28-0.50; OR 0.39, 95% CI, 0.28-0.58; OR 0.37, 95% CI 0.27-0.51 respectively) than those with lower incomes. ConclusionAdults under 65 with more CVD risk factors are at higher risk of CRMN. Hence, robust prescription drug coverage and targeted interventions are necessary to lower CRMN in those with CVD risk factors.

ObjectiveAs cannabis use has increased in the United States, so has cannabinoid hyperemesis syndrome (CHS), a disorder characterized by severe nausea, vomiting, and abdominal pain among heavy cannabis users. We previously showed that CHS symptoms are associated with several behavioral and psychological characteristics linked to psychosocial impairment. We examined links between CHS symptoms and suicidal thoughts, behaviors, and proximal suicide risk factors. MethodsWe used data from the National Firearms, Alcohol, Cannabis, and Suicide survey, a nationally representative survey of 7,034 US adults. Items assessed symptoms of CHS and suicidal thoughts and behaviors. Comparisons focused on: those with daily cannabis use and CHS symptoms (n = 191), those with daily cannabis use without CHS symptoms (n = 882), those with past year cannabis use but not daily use (n = 1288), and those without past year cannabis use (n = 4673). ResultsThose with CHS symptoms reported the highest prevalence of suicidal thoughts and behaviors with most lifetime rates being significantly higher than those with daily cannabis use without CHS symptoms. Those with CHS symptoms also reported higher mean-levels of thoughts and feelings associated with suicide (i.e., perceived burdensomeness, thwarted belongingness, defeat, entrapment) than all the other groups. ConclusionsThose with CHS symptoms reported especially high rates of suicidal thoughts, behaviors, and attempts even when compared to others with daily cannabis use. People with CHS symptoms appear to be at high risk of suicide, possibly related to distress from their gastrointestinal symptoms and psychiatric, substance use, and medical comorbidities.

* BackgroundUnderstanding the real-world impact of clinical trials is important for informing health care policy. This is particularly true when trials are designed to show changes in surrogate endpoints such as changes in risk factors rather than events or mortality. We developed an agent-based microsimulation that estimates the population-level benefits in each US state for cardiometabolic health interventions shown to improve risk factors. * MethodsWe designed a large-scale, location-specific agent-based simulation model with a population of 51 million in silico individuals and estimated results for the years 2023 to 2040 in 30-day steps for each of the 50 states and District of Columbia. Input data reflected current cardiometabolic health in each state and the effects of interventions and risk factors on outcomes. We constructed three health policy intervention scenarios based on successful randomized controlled trials designed to improve cardiometabolic population health: improved access to fixed-dose combination (FDC) antihypertensive medication, a pharmacist-led intervention to increase adherence to statin and antihypertensives medications at the time they are initiated (Pharmacy), and a community-based lifestyle and behavior intervention designed to prevent diabetes (Community). Outcomes included myocardial infarction, ischemic and non-ischemic heart failure, and ischemic stroke events, deaths, and disability-adjusted life years (DALYs). * ResultsOur simulation included a representative population of the United States, accurate at the age, sex, and state level, with individual people simulated over 17 years. By the year 2040, the FDC intervention was estimated to have prevented 776,000 (95% UI 578,000- 956,000) CVD DALYs and 44,600 (95% UI 32,700-55,600) deaths annually. Reductions in ischemic heart disease deaths accounted for 76.5% of the total reductions in CVD deaths. The Pharmacist intervention prevented 170,000 (95% UI 129,000-208,000) CVD DALYs, and the Community intervention prevented 152,000 (95% UI 128,000-173,000) CVD DALYs. * ConclusionsA fixed-dose combination of antihypertensives could prevent 1.2% of total CVD DALYs, with smaller benefits from adherence and lifestyle-focused programs and impact of interventions varying by state. The greatest reduction was in incident myocardial infarctions and ischemic heart disease deaths. Providing accurate population-level estimates at the state level can help local health policy decision-makers implement the most impactful interventions. Clinical PerspectiveWhat is new? O_LIUsing person-level simulation, we have translated randomized trial results showing improvements in blood pressure, BMI, fasting plasma glucose, and LDL-C, and adherence to medication into real-world impact including forecasting cardiovascular disease events and deaths for the United States through the year 2040. C_LIO_LIA national, agent-based microsimulation for all 50 US states and DC allows us to assess how risk factor interventions will differentially affect demographic groups and locations. C_LI What are the clinical implications? O_LIBroad adoption of fixed-dose combination medication for hypertension had the largest health benefit in all states. C_LIO_LIInterventions to improve adherence to medications or promote behavior change led to smaller reductions in disease burden. C_LIO_LIDirect comparison of the estimated real-world impact of clinical and community-based interventions can guide ongoing efforts to reduce the population burden of cardiovascular disease and resulting disparities. C_LI

ImportanceCannabinoid Hyperemesis Syndrome (CHS) is an emerging condition among those with heavy cannabis use characterized by persistent and severe nausea and vomiting. However, very little is known about the national prevalence of CHS, outside of healthcare settings, and among those who use cannabis frequently. ObjectiveTo determine the national prevalence of CHS symptoms, diagnosis, and associated characteristics. DesignA cross-sectional, nationally representative survey of US adults. SettingThe National Firearms, Alcohol, Cannabis, and Suicide survey was conducted in 2025. Participants7,034 US adults over 18 years old provided survey data. ExposuresNot applicable. Main Outcome and MeasuresItems were included that assess symptoms of CHS, along with multiple measures of cannabis use and problem use. ResultsThe prevalence of those reporting daily cannabis use in the past 5 years was 15.2%, corresponding to an estimated over 40 million US adults. Among those who used cannabis daily, 17.8% reported CHS-like symptoms (i.e., severe nausea, vomiting, or abdominal pain), which translates to an estimated 7.2 million US adults, or a 2.7% national prevalence rate. Only 11.5% of those with a symptom prolife consistent with CHS reported receiving a CHS diagnosis from a medical provider. Respondents reporting CHS symptoms were younger, more likely to be female and non-White race, lower income, less educated, and endorsed more cannabis use problems relative to those who used cannabis daily or less frequently. Conclusions and RelevanceA small but significant number of US adults with daily cannabis use reported symptoms consistent with CHS. Beyond patterns of cannabis use, those with CHS symptoms had fewer economic resources and endorsed more cannabis-related problems, even when compared to others with daily cannabis use. Most people reporting CHS symptoms were not diagnosed by a medical provider, suggesting that there may be a substantial cohort who is experiencing CHS symptoms but is not seeking medical treatment or having their condition recognized by medical providers. As cannabis use increases, it is likely that CHS will also become more common, underscoring the importance of expanded research on this condition. KEY POINTSO_ST_ABSQuestionC_ST_ABSHow frequently do people who use cannabis daily experience symptoms of Cannabinoid Hyperemesis Syndrome (CHS)? FindingsIn this nationally representative survey, 17.8% of those with daily cannabis use reported CHS-like symptoms (severe nausea, vomiting, or abdominal pain), which translates to over 7 million US adults. Those reporting CHS symptoms were younger, more likely to be female and non-White race, lower income, less educated, and endorsed more cannabis use problems relative to those who used cannabis daily and those who used less frequently. MeaningA significant proportion of those who use cannabis daily report symptoms consistent with CHS.

We use geospatial data to examine the unprecedented national program currently underway in the United States to distribute and administer vaccines against COVID-19. We quantify the impact of the proposed federal partnership with the company Dollar General to serve as vaccination sites and compare vaccine access with Dollar General to the current Federal Retail Pharmacy Partnership Program. Although dollar stores have been viewed with skepticism and controversy in the policy sector, we show that, relative to the locations of the current federal program, Dollar General stores are disproportionately likely to be located in Census tracts with high social vulnerability; using these stores as vaccination sites would greatly decrease the distance to vaccines for both low-income and minority households. We consider a hypothetical alternative partnership with Dollar Tree and show that adding these stores to the vaccination program would be similarly valuable, but impact different geographic areas than the Dollar General partnership. Adding Dollar General to the current pharmacy partners greatly surpasses the goal set by the Biden administration of having 90% of the population within 5 miles of a vaccine site. We discuss the potential benefits of leveraging these partnerships for other vaccinations, including against influenza.

BackgroundSubstantial geographic disparities in cardiovascular disease (CVD) mortality persist across the United States. The extent to which "place" reflects underlying socioeconomic and behavioral risk factors remains insufficiently explained. This study applies machine learning to quantify the determinants of these disparities. MethodsA cross-sectional analysis linked county-level 2019-2020 age-adjusted CVD mortality rates from the CDC with health determinant metrics from the 2023 County Health Rankings dataset. The analytic sample included [N counties] with complete data. A Random Forest regressor modeled mortality outcomes, incorporating socioeconomic, healthcare access, and behavioral predictors. Model interpretation used SHAP to assess feature-level contributions. ResultsThe model explained [R2 value] of variance in CVD mortality. Socioeconomic factors, particularly median household income and poverty rates, were the most influential predictors, followed by county-level smoking prevalence. Geographic identifiers alone had limited explanatory value after accounting for socioeconomic and behavioral metrics. ConclusionsGeographic disparities in CVD mortality are explained by underlying socioeconomic disadvantage and community health behaviors. Effective reduction of disparities requires public health interventions addressing poverty, education, and behavioral risk factors beyond clinical care. What Is New?Explanatory vs. Predictive Modeling: Previous research has largely focused on identifying geographic disparities in cardiovascular disease (CVD) mortality. This study goes further by not only predicting mortality but also explaining why disparities exist, quantifying the relative importance of socioeconomic, behavioral, and healthcare access determinants. Advanced InterpretationWe apply SHAP (SHapley Additive exPlanations), an advanced interpretability framework in machine learning, to measure precisely the effect of each county-level characteristic on mortality, uncovering complex patterns and interactions. Integrated Data ApproachBy combining recent granular datasets on health outcomes, socioeconomic context, and behaviors, this study produces a multi-domain explanatory model of CVD mortality drivers at the national scale. Clinical ImplicationsFindings show that clinical interventions alone are insufficient to eliminate disparities in CVD mortality, since the most powerful predictors are upstream social determinants of health. This evidence supports the need for clinicians and health systems to partner in policies that address economic stability, educational access, and environments conducive to healthier behaviors. Strategic targeting of resources toward communities with high poverty and low educational attainment may yield more effective and equitable reductions in the national CVD burden compared to approaches focused only on clinical care.

BACKGROUNDTelehealth has emerged as an effective tool for managing common chronic conditions such as hypertension, especially during the COVID-19 pandemic. However, the impact of state telehealth payment and coverage parity laws on hypertension management remains uncertain. METHODSData from the MerativeTM MarketScan(R) Commercial Claims and Encounters Database from January 1, 2016 to December 31, 2021 were used to construct the study cohort. The sample included non-pregnant individuals aged 25-64 years with hypertension. We reviewed and coded telehealth parity laws related to hypertension management in all 50 states and the District of Columbia, distinguishing between payment parity laws and coverage parity laws. The primary outcomes were antihypertension medication use, measured by the average medication possession ratio (MPR), medication adherence (MPR [≥]80%), and average number of days of drug supply. We used a generalized difference-in-difference (DID) design to examine the impact of these laws. Results were presented as marginal effects and 95% confidence intervals (CI). RESULTSAmong 353,220 individuals, states with payment parity laws were significantly linked to increased average MPR by 0.43 percentage point (95% CI: 0.07 - 0.79), and an increase of 0.46 percentage point (95% CI: 0.06 - 0.92) in the probability of medication adherence. Payment parity laws also led to an average increase of 2.14 days (95% CI: 0.11 - 4.17) in antihypertensive drug supply, after controlling for state-fixed effects, year-fixed effects, individual sociodemographic characteristics and state time-varying covariates including unemployment rates, GDP per capita, and poverty rates. In contrast, coverage parity laws were associated with a 2.13-day increase (95% CI: 0.19 - 4.07) in days of drug supply, but did not significantly increase the average MPR or probability of medication adherence. In addition, telehealth payment or coverage parity laws were positively associated with the number of hypertension-related telehealth visits, but this effect did not reach statistical significance. These findings were consistent in sensitivity analyses. CONCLUSIONSState telehealth payment parity laws were significantly associated with greater medication adherence, whereas coverage parity laws were not. With the increasing adoption of telehealth parity laws across states, these findings may support policymakers in understanding potential implications on management of hypertension. Clinical Perspective What Is New?Telehealth is an effective tool to manage hypertension and state-level telehealth parity laws can influence its application. Prior studies have not clearly differentiated between the impacts of payment parity and coverage parity. Using a quasi-experimental generalized difference-in-differences design, we assessed the effects of telehealth payment parity and coverage parity laws on hypertension management. Our study found that state telehealth payment parity laws were significantly associated with increased hypertension medication adherence, while coverage parity laws were not. What Are the Clinical Implications?The widespread adoption of telehealth payment parity laws may significantly impact hypertension management, during emergencies like the COVID-19 pandemic and beyond. Considering that hypertension impacts approximately half of the adult population, our study provides valuable insights into the potential benefits of telehealth parity laws for private payers in enhancing the management of hypertension. With the increasing adoption of telehealth parity laws across states, integrating telehealth into hypertension management holds significant implications for the evolving U.S. healthcare system in the digital age.

BackgroundAs cigarette smoking continues declining among youth and young adults, smoking rates among older Americans remain unchanged. Historically, cigarette and, more recently, e-cigarette tax policies influenced smoking behavior in younger smokers. Understanding how older smokers respond to tax changes can inform public health strategies. MethodsWe assembled a quarterly panel of state cigarette and e-cigarette tax rates using the CDC STATE System Tobacco (2000-2024) and E-Cigarette Legislation databases (2015-2024), then merged these data to individual-level survey responses from the Behavioral Risk Factor Surveillance System (BRFSS). Our sample included all adults aged [≥]65, but our main specification included adults with a history of smoking. We estimated two-way fixed-effects population-weighted linear probability regression models of current smoking and past-year quit attempts. ResultsAmong 3,117,382 adults, 50% had a history of smoking; from which 18% currently smoked. A one-dollar tax increase was associated with current smoking: cigarette tax = -0.61-percentage points (CI = -0.94,-0.28); e-cigarette tax = +0.19-percentage-points (CI = 0.14,0.24). There was no association between cigarette taxes and quit attempts. A one-dollar increase in e-cigarette tax was associated with reduced quit attempts (-0.17-percentage-points; CI = -28,-0.06). Approaching tax parity by one dollar was associated with increased current smoking by 0.23-percentage-points (CI = 0.16,0.29) and reduced quit attempts by -0.17-percentage-points (CI = -0.29,0.05). ConclusionsOlder American smokers appear responsive to cigarette and e-cig tax changes. Policies increasing the relative cost of e-cigarettes may impede cessation and perpetuate smoking rates in older generations at the highest risk of smoking related harm. ImplicationsMany studies have investigated the impact of cigarette and e-cigarette tax changes on smoking behavior in youth or younger adults. This study adds new evidence quantifying how new cigarette and e-cigarette taxes change smoking behavior among older adults, a population yet to realize reductions in smoking despite higher risk of tobacco related harm. Analyzing large, population-based survey data, we show that older smokers change smoking behavior due to cigarette and e-cigarette taxes. Taxation of e-cig products may produce unintended harm among older smokers. Specifically, approaching tax parity may increase cigarette smoking and reduce quit attempts among older adults with a history of smoking.

Melanoma imposes substantial clinical and financial burdens, particularly in advanced stages where systemic therapies are increasingly utilized. To establish a baseline for evaluating the statewide War on Melanoma (WoM) early detection initiative, we analyzed stage-specific melanoma expenditures in Oregon from 2011-2021 using a novel pseudostaging algorithm applied to the Oregon All Payer All Claims (APAC) database. The algorithm classified cases into early (in situ/localized), regional, and distant stages based on diagnostic, procedural, and treatment codes and was validated against SEER-Medicare claims and chart review. Over the study period, the number of melanoma cases in claims rose steadily, and total annual expenditures tripled, driven primarily by late-stage disease. Expenditures for early-stage melanoma remained relatively stable, while costs for regional and distant stages increased sharply with the adoption of immune checkpoint inhibitors and targeted therapies. These findings provide the first comprehensive, claims-based baseline of stage-specific melanoma costs in Oregon and highlight the disproportionate economic burden of advanced disease. Establishing such baselines is critical for evaluating population-level initiatives like WoM and for assessing the potential economic benefits of earlier detection and treatment. SummaryO_LIWe quantified the stage-specific economic burden of melanoma in Oregon using a pseudostaging algorithm applied to statewide claims data, demonstrating sharp increases in cost, particularly in advanced disease. C_LIO_LIThese estimates provide essential baseline evidence for evaluating the War on Melanoma, a statewide initiative designed to promote earlier detection and reduce the need for costly late-stage treatment. C_LIO_LIThe reproducible claims-based approach offers a scalable framework for other states and health systems to assess the value of cancer prevention and early detection initiatives. C_LI SignificanceWe establish stage-specific costs of melanoma in Oregon using a validated claims-based pseudostaging algorithm. The results highlight the disproportionate financial burden of advanced disease and provide essential context for the War on Melanoma, a statewide early detection initiative. These baseline estimates enable rigorous evaluation of whether shifting toward earlier-stage diagnosis can reduce healthcare costs and improve patient outcomes, offering a framework relevant to other states and cancer prevention programs.

BackgroundMedical treatment decisions are often based on estimated global risk scores. When heterogeneity in treatment effects exists, assigning treatment according to estimated individualized treatment rules (ITRs) instead has the potential to improve mean outcomes. To investigate racial and ethnic group differences in treatment rates when comparing antihypertensive medication recommendations from an estimated ITR with a risk score approach. MethodsData were simulated to emulate observational data with underlying treatment effect heterogeneity in survival times. An ITR and risk score approach were compared to illustrate how the resulting recommendations may disagree. An ITR for prescribing antihypertensives was estimated from 3,281 adults from the Multi-Ethnic Study of Atherosclerosis (MESA), an observational longitudinal cohort study, and compared to the risk-based approach recommended by cardiovascular care guidelines. Hypothetical treatment rates under each "rule" were computed. In the simulation study, the proportion of individuals treated optimally under each rule was calculated. Using MESA, a Chi-square test of independence was performed to determine whether treatment rates differed across racial and ethnic groups. ResultsTwo benefits of ITRs were shown: they (1) maximize expected survival times and (2) may mitigate racial disparities when treatment effect heterogeneity is expected. Using MESA, the ITR recommended treatment to more participants than the risk score approach across all racial and ethnic groups. A Chi-square test suggested that treatment rates for different "rules" differed significantly across racial and ethnic groups (p < .001). ConclusionTreatment recommendations varied substantially when assigning treatment using an ITR versus a risk-based approach.

Governments are considering financial incentives to increase vaccine uptake to end the COVID-19 pandemic. Incentives being offered include cash-equivalents such as vouchers or being entered into lotteries. Our experiment involved random assignment of 1,628 unvaccinated participants in the United States to one of three 45 second informational videos promoting vaccination with messages about: (a) health benefits of COVID-19 vaccines (control); (b) being entered into lotteries; or (c) receiving cash equivalent vouchers. After seeing the control health information video, 16% of individuals wanted information on where to get vaccinated. This compared with 14% of those assigned to the lottery video (odds ratio of 0.82 relative to control: 95% credible interval 0.57-1.17) and 22% of those assigned to the cash voucher video (odds ratio of 1.53 relative to control: 95% credible interval 1.11-2.11). These results support greater use of cash vouchers to promote COVID-19 vaccine uptake and do not support the use of lottery incentives.

ImportanceThe U.S. FDA has proposed a product standard that would reduce the nicotine content and addictiveness of cigarettes. It is unclear what impact this would have on economic outcomes or priority populations who are disproportionately harmed by tobacco use, such as people with major depression. ObjectiveTo evaluate the long-term health and economic impacts of a nicotine product standard for the U.S. population by depression status. Design, Setting, and ParticipantsA microsimulation model was developed and calibrated to National Survey on Drug Use and Health (NSDUH) 2005-2023 data on smoking, vaping, and depressive episodes. The anticipated effects of the nicotine product standard on smoking and vaping were obtained from an FDA expert elicitation and used to simulate the policy from 2027-2100. ExposureSmoking and vaping. Main Outcome(s) and Measure(s)Health outcomes included prevalence of smoking and vaping, deaths, and life years gained overall and by major depression status. Economic outcomes include direct costs to the healthcare system and societal costs. ResultsUnder the proposed nicotine product standard, smoking is projected to decline to <1% for people with and without depression by 2100. The policy is estimated to avert 1.7 million premature deaths and lead to 74.7 million life years gained. Depression prevalence is also expected to decline, with 8.5 million fewer cases of depression estimated. Longer life expectancies under the policy are projected to increase medical costs by $296 billion, while also increasing worker productivity by $266 billion with an additional $1.2 trillion in consumer spending. Conclusions and RelevanceTimely implementation of a nicotine reduction strategy, either through a federal product standard or state-level sales restrictions, is cost-effective and could prevent millions of premature deaths and reduce smoking disparities by depression status.

On June 1, 2020, Massachusetts became the first state in the US to ban all flavored tobacco product sales, including menthol cigarettes. Recent research has estimated the reduction in cigarette sales in Massachusetts following the comprehensive tobacco flavor ban, but noted that missing data on border states was a major limitation of the findings. This letter replicates the procedures of Asare et al. with 1540 state-months and then adds Asare et al.s missing states with 2420 total observations for the period January 2017 to July 2021. The replication confirms Asare et al.s adjusted estimate for the reduction in menthol cigarettes, which falls within their 95% confidence interval. However, assigning Massachusetts and its bordering states as a single treatment group leads to an increase of 191.95 (95% CI, 96.82 to 287.09) total cigarette packs sold per 1000 people in the six-state region. In the 12-month period following the comprehensive flavor ban in Massachusetts, the state sold 29.96 million fewer cigarette packs compared to the prior period. However, a total of 33.36 million additional cigarette packs were sold during the same post-ban period in the counties that bordered Massachusetts. Given decreasing rates of smoking in all five bordering states between 2019 and 2020, the increase in border-state cigarette sales following the comprehensive flavor ban should be interpreted as a lower-bound estimate for cigarettes that were ultimately consumed in Massachusetts.

ObjectiveTo develop the Mexico Smoking and Vaping Model (Mexico SAVM) to estimate cigarette and electronic nicotine delivery systems (ENDS) prevalence and the public health impact of legalizing ENDS use. MethodsSAVM, a cohort-based discrete-time simulation model, compares two scenarios. The ENDS-Restricted Scenario estimates smoking prevalence and associated mortality outcomes under the current policy of an ENDS ban, using Mexico-specific population projections, death rates, life expectancy, and smoking and e-cigarette prevalence. The ENDS-Unrestricted Scenario projects smoking and vaping prevalence under a hypothetical scenario where ENDS use is allowed. The impact of legalizing ENDS use is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the ENDS-Restricted and Unrestricted scenarios. ResultsCompared to a national ENDS ban, The Mexico SAVM projects that legalizing ENDS use could decrease smoking prevalence by 40.1% in males and 30.9% in females by 2049 compared to continuing the national ENDS ban. This reduction in prevalence would save 2.9 (2.5 males and 0.4 females) million life-years and avert almost 106 (91.0 males and 15.5 females) thousand deaths between 2025 and 2049. Public health gains decline by 43% to 59,748 SVADs averted when the switching rate is reduced by half and by 24.3% (92,806 SVADs averted) with a 25% ENDS risk level from that of cigarettes but increased by 24.3% (121,375 SVADs averted) with the 5% ENDS risk. ConclusionsMexico SAVM suggests that greater access to ENDS and a more permissive ENDS regulation, simultaneous with strong cigarette policies, would reduce smoking prevalence and decrease smoking-related mortality. The unanticipated effects of an ENDS ban merit closer scrutiny, with further consideration of how specific ENDS restrictions may maximize public health benefits.