Luca Salmasi

The role of anti-smoking legislation on cigarette and alcohol consumption habits in Italy.

The short-term effects of public smoking bans on individual smoking and drinking habits were investigated in this paper. In 2005, a smoking ban was introduced in Italy, and we exploited this exogenous variation to measure the effect on both smoking participation and intensity and the indirect effect on alcohol consumption. Using data from the Everyday Life Aspects survey, for the period 2001-2007, we show that the introduction of smoke-free legislation in Italy significantly affected smoking behavior. We also document significant indirect effects on alcohol consumption for the main alcoholic beverage categories. A robustness analysis is also performed, to test the extent to which unobservable variables may bias our estimated parameters. Our results are then used to perform a cost-effectiveness analysis of the anti-smoking legislation in Italy.

Food prices and overweight patterns in Italy

In this paper, we examine the role of relative food prices in determining the recent increase in body weight in Italy. Cross-price elasticities of unhealthy and healthy foods estimated by a demand system provide a consistent framework to evaluate substitution effects, when a close association is assumed between unhealthy (healthy) foods and more (less) energy-dense foods. We used a dataset constructed from a series of cross-sections of the Italian Household Budget Survey (1997–2005) to obtain the variables of the demand system, which accounts for regional price variability. The relative increase in healthy food prices was found to produce nontrivial elasticities of substitution towards higher relative consumption of unhealthy foods, with effects on weight outcomes. In addition, these changes were unevenly distributed among individuals and were particularly significant for those who were poorer and had less education.

Does Cigarette Smoking Affect Body Weight? Causal Estimates from the Clean Indoor Air Law Discontinuity

This paper examines the causal effect of smoking on body weight in Italy. We take advantage of the discontinuity in smoking habits introduced by the Italian smoking ban in 2005. Our estimates indicate that the ban reduced smoking intensity by half a cigarette per day and smoking participation rate by 2 percentage points. We estimate a significant effect on body weight of about 1 kg. Heterogeneous effects are also found, highlighting a smaller impact on men, employees and overweight and obese people. Most of the weight variations are attributed to quitting smoking, whereas reductions in cigarette consumption are not significant.

Socio-demographic determinants and access to prenatal care in Italy

BackgroundMany governments have made commitments to examine inequalities in healthcare access based on studies assessing the association between several socio-demographic factors and late initiation or fewer prenatal examinations. This study addressed the question of whether socio-demographic determinants were significant in explaining differences in prenatal care in one administrative region of Italy, Umbria.MethodsData were obtained from the administrative source of the regional Standard Certificate of Live Births between 2005 and 2010, and were merged with Census data to include a socio-economic deprivation index. Standard and multilevel logistic regression models were used to analyze the magnitude of various individual-level maternal characteristics and socio-demographic indicators, such as nationality, employment status, education with respect to late access to the first examination, and low number of medical visits.ResultsThe study involved approximately 37,000 women. The heterogeneous effects of socio-demographic variables were documented on the prenatal care indicators analyzed. A multivariate model showed that women born outside Italy had a higher probability of making their first visit later than the 12th week of pregnancy and low numbers of prenatal medical visits; the estimated odds ratio for the analyzed indicators range from 2.25 to 3.05. Inadequate prenatal healthcare use was also observed in younger and pluriparous women and those with low education; in addition, having a job improved the use of services, possibly through transmission of information of negative consequences due to delayed or few prenatal visits. Interestingly, this study found a substantial reduction in the number of pregnant women who do not use prenatal healthcare services properly.ConclusionsThe aim of this research is to provide more accurate knowledge about the inadequate use of prenatal healthcare in Italy. Results highlight the existence of differences in healthcare use during pregnancy, especially for women from less advantaged social classes (i.e., unemployed or poorly educated). Such inequalities should be examined in all areas of public policy and public services, to ensure equal opportunity for their use.

Use of instrumental variables in electronic health record-driven models

Precision medicine presents various methodological challenges whose assessment requires the consideration of multiple factors. In particular, the data multitude in the Electronic Health Records poses interoperability issues and requires novel inference strategies. A problem, though apparently a paradox, is that highly specific treatments and a variety of outcomes may hardly match with consistent observations (i.e., large samples). Why is it the case? Owing to the heterogeneity of Electronic Health Records, models for the evaluation of treatment effects need to be selected, and in some cases, the use of instrumental variables might be necessary. We studied the recently defined person-centered treatment effects in cancer and C-section contexts from Electronic Health Record sources and identified as an instrument the distance of patients from hospitals. We present first the rationale for using such instrument and then its model implementation. While for cancer patients consideration of distance turns out to be a penalty, implying a negative effect on the probability of receiving surgery, a positive effect is instead found in C-section due to higher propensity of scheduling delivery. Overall, the estimated person-centered treatment effects reveal a high degree of heterogeneity, whose interpretation remains context-dependent. With regard to the use of instruments in light of our two case studies, our suggestion is that this process requires ad hoc variable selection for both covariates and instruments and additional testing to ensure validity.

Investigating the poverty-obesity paradox in Europe

&NA; This paper investigates the effect of income‐ and wealth‐based poverty on the probability of being obese for the elderly in Europe by analysing data drawn from the Survey of Health, Ageing and Retirement (SHARE) and the English Longitudinal Study of Ageing (ELSA). We use early‐life economic conditions and regional circumstances as instruments for poverty later in life to account for endogeneity issues. After controlling for a large set of covariates at the individual, household, regional and country level, the results show that poverty significantly increases the probability of being obese and the Body Mass Index (BMI), for men and women. The results show that, accounting for endogeneity with a bivariate probit model, poor individuals are from 10 to 20% points more likely to be obese than non‐poor individuals. The effect on BMI ranges from 0.295 points (2.39 kg) to 0.395 points (2.75 kg). These results are robust to a series of checks and suggest that anti‐poverty interventions might have positive side effects in terms of reducing food‐related health inequalities.

The effect of smoking habit changes on body weight: Evidence from the UK.

This paper evaluates the causal relationship between smoking and body weight through two waves (2004-2006) of the British Household Panel Survey. We model the effect of changes in smoking habits, such as quitting or reducing, and account for the heterogeneous responses of individuals located at different points of the body mass distribution by quantile regression. We test our results by means of a large set of control groups and investigate their robustness by using the changes-in-changes estimator and accounting for different thresholds to define smoking reductions. Our results reveal the positive effect of quitting smoking on weight changes, which is also found to increase in the highest quantiles, whereas the decision to reduce smoking does not affect body weight.

Economic Evaluation of the effect of Quitting Smoking on Weight Gains: Evidence from the United Kingdom

OBJECTIVE This article estimated the causal effect of quitting smoking on body weight gains in the United Kingdom to evaluate whether savings in health costs deriving from smoking prevention and its related diseases are greater than the costs associated with increased obesity. METHODS We used a longitudinal data set extracted from two waves (2004-2006) of the British Household Panel Survey, which includes information on smoking and a large number of sociodemographic variables. We modeled the effect of quitting smoking on body weight accounting for heterogeneous responses from individuals belonging to different clinical classes of body mass index (BMI) (i.e., overweight and obese individuals). National Health Service costs associated with smoking were then used to implement a cost-benefit analysis, comparing the advantages of smoking reductions with the costs associated with increased obesity. RESULTS The BMI was found to increase by 0.26 points for quitters compared with those who continued to smoke. The estimated BMI increase was larger for overweight (0.49 points) and obese (0.76 points) people. This result does not change when different control groups are examined. From an economic perspective, the National Health Service cost reductions attributable to quitting smoking were £156.81 million whereas the lost benefit for unintended increases in body weight was £24.07 million. CONCLUSIONS This article found that the health benefits associated with quitting smoking are greater than the costs associated with increased overweight and obesity.

Health and income inequalities in Europe: What is the role of circumstances?

&NA; Equality of opportunity theories distinguish between inequalities due to individual effort and those due to external circumstances. Recent research has shown that half of the variability in income of World population was determined by country of birth and income distribution. Since health and income are generally strictly related, the aim of this paper is to estimate how much variability in income and health is determined by external circumstances. We use data from the Survey of Health, Ageing and Retirement (SHARE) and the English Longitudinal Survey on Ageing (ELSA), two comparable multidisciplinary surveys that provide micro‐level data on health and financial resources among the elderly for a large number of European countries. Our baseline estimation shows that about 20% of the variability in income is explained by current country‐specific circumstances, while health outcomes range from 12% using BMI to 19% using self‐rated health. By including early‐life circumstances, the explained variability increases almost 20 percentage points for income and for self‐rated health but less for other health outcomes. Finally, by controlling for endogeneity issues linked with effort, our estimates indicate that circumstances better explain variability in health outcomes. Results are robust to some tests, and the implications of these findings are discussed.

Estimating the Smoking Ban Effects on Smoking Prevalence, Quitting and Cigarette Consumption in a Population Study of Apprentices in Italy.

Objectives: We evaluated the effects of the Italian 2005 smoking ban in public places on the prevalence of smoking, quitting and cigarette consumption of young workers. Data and Methods: The dataset was obtained from non-computerized registers of medical examinations for a population of workers with apprenticeship contracts residing in the province of Viterbo, Italy, in the period 1996–2007. To estimate the effects of the ban, a segmented regression approach was used, exploiting the discontinuity introduced by the application of the law on apprentices’ smoking behavior. Results: It is estimated that the Italian smoking ban generally had no effect on smoking prevalence, quitting ratio, or cigarette consumption of apprentices. However, when the estimates were applied to subpopulations, significant effects were found: −1% in smoking prevalence, +2% in quitting, and −3% in smoking intensity of apprentices with at least a diploma.