Kenneth E. Warner

Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities

National Academy of Sciences • National Academy of Engineering • Institute of Medicine • National Research Council Mental, emotional, and behavioral (MEB) disorders—which include depression, conduct disorder, and substance abuse—affect large numbers of young people. Studies indicate that MEB disorders are a major health threat and are as commonplace today among young people as a fractured limb—not inevitable but not at all unusual. Almost one in five young people have one or more MEB disorders at any given time. Among adults, half of all MEB disorders were first diagnosed by age 14 and three-fourths by age 24.

Investing in youth tobacco control: a review of smoking prevention and control strategies

OBJECTIVE To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the United States, including strategies that have undergone evaluation and emerging innovations that have not yet been assessed for efficacy. DATA SOURCES Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates. DATA SYNTHESIS Interventions and policy approaches that have been assessed or evaluated were categorised using a typology with seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, tobacco excise taxes, and direct restrictions on smoking). Novel and largely untested interventions were described using nine categories. CONCLUSIONS Youth smoking prevention and control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation, including aggressive media campaigns, teen smoking cessation programmes, social environment changes, community interventions, and increasing cigarette prices. A significant proportion of the resources obtained from the recent settlement between 46 US states and the tobacco industry should be devoted to expanding, improving and evaluating “youth centred” tobacco prevention and control activities.

Hardening and the hard-core smoker: Concepts, evidence, and implications

A nascent debate pits researchers who believe that hard-core smokers are coming to dominate the remaining population of smokers against others who perceive the hardening of the target as a far more distant concern. At stake is the future emphasis of tobacco control: should we alter the current allocation of resources between treatment of individual smokers and modification of the psychosocial environment through public education and policy measures? We review the evidence and conclude that: (1) hardening is probably occurring in the sense that, compared with earlier generations, many of todays smokers possibly do have greater difficulty quitting, or are inherently less willing to do so. (2) Hardening may be most usefully construed in the context of specific groups of smokers, such as the mentally ill, who may constitute a growing fraction of the remaining smoking population. (3) Using conventional measures, however, we find little evidence that the population of smokers as a whole is hardening. Cessation rates have not decreased. (4) Truly hard-core smokers necessarily constitute a very small fraction of the population. Quitting-susceptible smokers continue to dominate the smoking population. (5) Hardening and the potential existence of true hard-core smokers recommend creative thinking about, and devotion of resources to, finding new ways to help the most dependent smokers to quit. (6) Sound research recommends the expansion of comprehensive tobacco-control programs in both the public and private sectors, and does not support reallocation of resources from such programs toward more intensive individualized treatment. We can afford both.

Medical costs of smoking in the United States: estimates, their validity, and their implications

OBJECTIVE To compare estimates of the medical costs of smoking in the United States and to consider their relevance to assessing the costs of smoking in developing countries and the net economic burden of smoking. DATA SOURCES A Medline search through early 1999 using keywords “smoking” and “cost”, with review of article reference lists. STUDY SELECTION Peer-reviewed papers examining medical costs in a single year, covering the non-institutionalised American population. DATA EXTRACTION Methods underlying study estimates were identified, described, and compared with attributable expenditure methodology in the literature dealing with costs of illness. Differences in methods were associated with implied differences in findings. DATA SYNTHESIS With one exception, the studies find the annual medical costs of smoking to constitute approximately 6–8% of American personal health expenditures. The exception, a recent study, found much larger attributable expenditures. The lower estimates may reflect the limitation of analysis to costs associated with the principal smoking-related diseases. The higher estimate derives from analysis of smoking-attributable differences in all medical costs. However, the finding from the most recent study, also considering all medical costs, fell in the 6–8% range. CONCLUSIONS The medical costs of smoking in the United States equal, and may well exceed, the commonly referenced figure of 6–8%. This literature has direct methodological relevance to developing countries interested in assessing the magnitude of their current cost-of-smoking burden and their future burdens, with differences in tobacco use histories and the availability of chronic disease treatment affecting country-specific estimates. The debate over the use of gross or net medical cost estimates is likely to intensify with the proliferation of lawsuits against the tobacco industry to recover expenditures on tobacco-produced disease.

Nondaily Smokers: Who Are They?

OBJECTIVE We sought to understand who constitutes the sizable population of nondaily, or some-day (SD), smokers. METHODS We analyzed descriptive statistics and regression results using the 1998-1999 Current Population Survey Tobacco Use Supplement to determine the prevalence of SD smokers, their sociodemographic characteristics, and the smoking patterns and histories of groups differentiated by the length and stability of their SD smoking. RESULTS SD smokers make up 19.2% of all current smokers. Among SD smokers, 44.6% have smoked less than daily for at least 1 year, no more than 14.4% are just starting to smoke, and the rest are likely in transition. Overall, SD smokers smoked a mean of 102 cigarettes per month (compared to 566.4 for daily smokers), on an average of 14.5 days out of the past 30. CONCLUSIONS SD smokers make up a substantial segment of the smoking population. They are not just beginning to smoke nor trying to quit. Many have developed a long-standing pattern of nondaily smoking, smoking relatively few cigarettes on the days when they do smoke. They are not substantially younger than daily smokers, as one might expect.

The economics of tobacco: myths and realities

Each side in the debate about tobacco control—the tobacco industry and the public health community—wields a seemingly powerful set of economic arguments, the industry claiming that economic considerations urge a “go slow” approach to tobacco control, the public health community insisting they recommend an aggressive stance. Each of the most prominent arguments presented by both sides has a kernel of truth to it; yet each, in its own way, represents only a half truth. The industry uses its economic appeal with full knowledge of and intent to exploit its ability to deceive and mislead policy makers and the public. In contrast, tobacco control advocates frequently employ their economic rationale without full appreciation of its limitations. To inform both tobacco control advocates and policy makers more fully, this paper identifies the principal economic myths concerning tobacco and discusses their realities. The myths are associated with their purveyors by initials: TI for Tobacco Industry myths, and TC for myths perpetuated by the Tobacco Control community. : Regardless of its health consequences, tobacco is crucial to a nations (or regions) economy. Without the cultivation of tobacco, manufacture of tobacco products, and distribution and sale of products, a countrys economy will suffer devastating economic consequences. Jobs will be lost, incomes will fall, tax revenues will plummet, and trade surpluses will veer dangerously in the direction of deficits . ### REALITY This is the tobacco industrys favourite economic myth. Conveyed to legislators and cabinet ministers (and journalists), its intent is to encourage the development of an indigenous tobacco industry within a given country, or to discourage the adoption of tobacco control policies likely to decrease tobacco product consumption. The half truth in this myth resides in the fact that tobacco farming and product manufacture, distribution, and sale do constitute significant economic activities in many economies, and in the world as a whole. Globally, according to tobacco industry estimates, 33 million people farm tobacco, albeit many of them part time and most in addition to other crops.1 Approximately half that number work in tobacco product manufacture, distribution, and retailing. In addition, another 10 million or so are employed in supplier industries providing materials and services to the tobacco …

Chapter 29 The economics of smoking

Abstract While the tobacco industry ranks among the most substantial and successful of economic enterprises, tobacco consumption is associated with more deaths than any other product. Economic analysis of the markets for tobacco products, particularly cigarettes, has contributed considerable insight to debates about the importance of the industry and the appropriate roles of public policy in grappling with the health consequences of tobacco. Certainly the most significant example of this phenomenon has been the rapidly expanding and increasingly sophisticated body of research on the effects of price increases on cigarette consumption. Because excise tax comprises an important component of price, the resultant literature has played a prominent role in legislative debates about using taxation as a principal tool to discourage smoking. In addition to informing legislative debates, this literature has contributed both theory and empirical evidence to the growing interest in modeling the demand for addictive products. This chapter examines this body of research in detail, as well as a variety of equity and efficiency concerns accompanying debates about cigarette taxation. Coverage also includes economic analysis of the role of other tobacco control policies, such as restrictions on advertising, of special interest due to their prominence in debates about tobacco control. The chapter concludes with consideration of research addressing the validity of the tobacco industrys argument that its contributions to employment, tax revenues, and trade balances are vital to the economic health of states and nations. This argument is one of the industrys principal weapons in its battle against policy measures intended to reduce tobacco product consumption.

Effects of Snowfalls on Motor Vehicle Collisions, Injuries, and Fatalities

OBJECTIVES We estimated the effects of snowfalls on US traffic crash rates between 1975 and 2000. METHODS We linked all recorded fatal crashes (1.4 million) for the 48 contiguous states from 1975 through 2000 to daily state weather data. For a subsample including 17 states during the 1990s, we also linked all recorded property-damage-only crashes (22.9 million) and nonfatal-injury crashes (13.5 million) to daily weather data. Employing negative binomial regressions, we investigated the effects of snowfall on crash counts. Fixed effects and other controls were included to address potential confounders. RESULTS Snow days had fewer fatal crashes than dry days (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90, 0.97), but more nonfatal-injury crashes (IRR = 1.23; 95% CI = 1.18, 1.29) and property-damage-only crashes (IRR=1.45; 95% CI=1.38, 1.52). The first snowy day of the year was substantially more dangerous than other snow days in terms of fatalities (IRR = 1.14; 95% CI=1.08, 1.21), particularly for elderly drivers (IRR=1.34; 95% CI=1.23, 1.50). CONCLUSIONS The toll of snow-related crashes is substantial. Our results may help estimate the potential benefits of safety innovations currently proposed by meteorology and traffic safety experts.

Cost effectiveness of smoking-cessation therapies. Interpretation of the evidence-and implications for coverage.

SummarySmoking cessation has been called the ‘gold standard’ of healthcare cost effectiveness, producing additional years of life at costs that are well below those estimated for a wide range of healthcare interventions. However, the most effective approaches to smoking cessation are not the most cost effective.As we move from the least resource-intensive interventions (e.g distribution of self-help cessation guides) to those that are most resource-intensive (e.g. medical treatments, including the use of nicotine replacement products), both cost and effectiveness increase, but cost increases more rapidly. Nevertheless, it must be considered that different interventions are effective for different people. Resource-intensive treatments may actually be far more cost effective for many people who may not respond to less-intensive interventions. A considered review of the evidence recommends support of all of the major forms of smoking-cessation intervention; even the most expensive are highly cost effective compared with the majority of medical practices that have been studied.Despite their cost effectiveness, smoking-cessation services are not covered by many healthcare providers. This review concludes that such coverage is warranted, primarily because much less cost-effective secondary and tertiary care is covered, encouraging its utilisation, rather than primary prevention. However, the argument favouring coverage is not as clear-cut as might be assumed. Coverage of smoking cessation amounts to a direct subsidy for smokers who want to quit. It is not health ‘insurance’ in the theoretical meaning of the term. The distinction is important as healthcare systems contemplate future coverage of a range of behaviour-related preventive interventions.

Decrease in the Prevalence of Environmental Tobacco Smoke Exposure in the Home During the 1990s in Families With Children

OBJECTIVES This study explored correlates with and changes in the prevalence of environmental tobacco smoke (ETS) exposure of children in the home. METHODS We used multiple logistic regression to explore ETS exposures as reported in the 1992 and 2000 National Health Interview Survey. RESULTS ETS exposure in homes with children declined from 35.6% to 25.1% (P <.001) between 1992 and 2000, whereas smoking prevalence declined 26.5% to 23.3%. Home ETS exposures were more prevalent among non-Hispanic Whites than among African Americans (adjusted odds ratio [AOR] = 0.702; 95% confidence interval [CI] = 0.614, 0.802), Asian Americans (AOR = 0.534; 95% CI = 0.378, 0.754), and Hispanics (AOR = 0.388; 95% CI = 0.294, 0.389). Exposures declined across all groups, with greater gains in higher education and income groups. CONCLUSIONS Home ETS exposure declined sharply between 1992 and 2000, more than would be predicted by the decline in adult smoking prevalence.