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BACKGROUND: The objective of this study is to estimate occupational differences in self-rated health, both in cross-section and over time, among older individuals. METHODS: We use hierarchical linear models to estimate self-reported health as a function of 8 occupational categories and key covariates. We examine self-reported health status over 7 waves (12 years) of the Health and Retirement Study. Our study sample includes 9,586 individuals with 55,389 observations. Longest occupation is used to measure the cumulative impact of occupation, address the potential for reverse causality, and allow the inclusion of all older individuals, including those no longer working. RESULTS: Significant baseline differences in self-reported health by occupation are found even after accounting for demographics, health habits, economic attributes, and employment characteristics. But contrary to our hypothesis, there is no support for significant differences in slopes of health trajectories even after accounting for dropout. CONCLUSIONS: Our findings suggest that occupation-related differences found at baseline are durable and persist as individuals age. [ABSTRACT FROM AUTHOR]

Objective: This study examines the degree to which a married individual's health habits and use of preventive medical care are influenced by his or her spouse's behaviors.Study Design: Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouse's health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot.Data Source: This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis.Sample: The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves.Principal Findings: We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors.Conclusions: Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures. [ABSTRACT FROM AUTHOR]

In 2004, Alcoa introduced a new health benefit for a portion of its workforce, which eliminated cost sharing for preventive care while increasing cost sharing for many other services. In this era of increased consumerism, Alcoa's benefit redesign constituted an effort to reduce health care costs while preserving use of targeted services. Taking advantage of a unique natural experiment, we find that Alcoa was able to maintain rates of preventive service use. This evidence suggests that differential cost sharing can be used to preserve the use of critical health care services. [ABSTRACT FROM AUTHOR]

Retirement, a major transition in the life course, may affect many aspects of retirees' well-being, including health and health care utilization. Leveraging differential statutory retirement age (SRA) by occupation for China's urban female workers, we provide some of the first evidence on the causal effect of retirement on hospitalizations attributable to mental illness and its heterogeneity. To address endogeneity in retirement decisions, we take advantage of exogeneity of the differing SRA cut-offs for blue-collar (age 50) and white-collar (age 55) female urban employees. We apply a Fuzzy Regression Discontinuity Design (RDD) around the SRA cut-offs using nationally representative hospital inpatient claims data that cover these workers. We show that blue-collar females incur more hospitalizations for mental illness after retirement, while no similar change is found for white-collar females. Conditional on blue-collar females being hospitalized, probabilities of overall and ER admissions due to mental illness increase by 2.3 and 1.2 percentage points upon retirement, respectively. The effects are primarily driven by patients within the categories of schizophrenia, schizotypal and delusional disorders; and neurotic, stress-related and somatoform disorders. Moreover, the 'Donut' RDD estimates suggest that pent-up demand at retirement unlikely dominates our findings for blue-collar females. Rather, our results lend support to their worsening mental health at retirement. These findings suggest that occupational differences in mental illness and related health care utilization at retirement should be considered when optimizing retirement policy schemes., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: A pressing tobacco policy concern is how to help smokers who have little interest in quitting cigarettes, a group that often suffers severe health consequences. By switching from cigarettes to e-cigarettes, they could obtain nicotine, potentially with less harm. We examined if policy-relevant attributes of cigarettes/e-cigarettes might encourage these smokers to switch to e-cigarettes., Methods: An online survey and discrete choice experiment on a nationally-representative sample of adult smokers in the US who reported low interest in quitting (n=2000). We modelled preference heterogeneity using a latent class, latent variable model. We simulated policies that could encourage switching to e-cigarettes., Results: Participants formed two latent classes: (1) those with very strong preferences for their own cigarettes; and (2) those whose choices were more responsive to policies. The latter group's choices were only somewhat responsive to menthol cigarette bans and taxes; the former group's choices were unresponsive., Conclusions: The policies studied seem unlikely to encourage harm reduction for individuals with little interest in quitting smoking., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We evaluate whether a combination of financial incentives and deposit contracts improves cessation rates among low- to moderate-income smokers., Methods: We randomly assigned 311 smokers covered by Medicaid at 12 health clinics in Connecticut to usual care or one of the three treatment arms. Each treatment arm received financial incentives for two months and either (i) nothing further ("incentives only"), (ii) the option to start a deposit contract with incentive earnings after the incentives ended ("commitment"), or (iii) the option to precommit any earned incentives into a deposit contract starting after the incentives ended ("precommitment"). Smoking cessation was confirmed biochemically at two, six, and twelve months., Results: At two, six, and twelve months after baseline, our estimated treatment effects on cessation are positive but imprecise, with confidence intervals containing effect sizes estimated by prior studies of financial incentives alone and deposit contracts alone. At two months, the odds ratio for quitting was 1.4 in the incentive-only condition (95% CI: 0.5 to 3.5), 2.0 for incentives followed by commitment (95% CI: 0.6 to 6.1), and 1.9 for incentives and precommitment (95% CI: 0.7 to 5.3)., Conclusions: A combined incentive and deposit contract program for Medicaid enrollees, with incentives offering up to $300 for smoking cessation and use of support services, produced a positive but imprecisely estimated effect on biochemically verified cessation relative to usual care and with no detectable difference in cessation rates between the different treatment arms., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Daren R. Anderson et al.)

Introduction: Use of JUULs and e-cigarettes is growing rapidly, particularly among adolescents. Research suggests that flavours may increase the appeal of these products, but little is known about how flavours influence perception. We examined whether youth perceptions about the health risks of JUULs and e-cigarettes vary with flavours., Methods: We conducted a national survey in 2018 of 1610 high-school students aged 14-18 who had ever heard of either JUULs or e-cigarettes. Respondents were asked to rate the lung cancer risk, the harm of second-hand vapour, potential for addiction and healthiness of differently flavoured JUUL and e-cigarette products. We investigated the relationship among flavour, risk perception and socio-demographic information., Results: We found that risk perceptions for both JUULs and e-cigarettes differ significantly by flavour type. Youths perceive fruit flavours to be less likely to lead to lung cancer (-0.909 (0.065)), have harmful second-hand vapour (-0.933 (0.060)) and be more addictive (1.104 (0.094)) relative to tobacco flavours. Candy, menthol/mint and alcohol flavours show similar patterns of risk association, although the magnitude is slightly smaller than for fruit flavours., Conclusions: Youths believe that flavours are related to the health risks of both JUULs and e-cigarettes despite the fact that these differences in risk by flavour have not been scientifically or systematically established. A policy concern is that misperceptions based on flavour may result in increased vaping by youths. The findings from this study support the assertion that banning fruit, menthol or mint and sweet flavours could reduce the appeal of JUULs and e-cigarettes to youth, with concomitant health protections., Competing Interests: Competing interests: No, there are no competing interests., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To estimate the impact of tobacco-21 laws on smoking among young adults who are likely to smoke, and consider potential social multiplier effects. Design Quasi-experimental, observational study using new 2016-17 survey data., Setting: United States., Participants/cases: A total of 1869 18-22-year-olds who have tried a combustible or electronic cigarette., Intervention and Comparators: Tobacco-21 laws raise the minimum legal sales age of cigarettes to 21 years. Logistic regressions compared the association between tobacco-21 laws and smoking among 18-20-year-olds with that for 21-22-year-olds. The older age group served as a comparison group that was not bound by these restrictions, but could have been affected by correlated factors. Age 16 peer and parental tobacco use were considered as potential moderators., Measurements: Self-reported recent smoking (past 30-day smoking) and current established smoking (recent smoking and life-time consumption of at least 100 cigarettes)., Findings: Exposure to tobacco-21 laws yielded a 39% reduction in the odds of both recent smoking [odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.42, 0.89] and current established smoking (OR = 0.61; 95% CI = 0.39, 0.97) among 18-20-year-olds who had ever tried cigarettes. This association exceeded the policy's relationship with smoking among 21-22-year-olds. For current established smoking, the tobacco-21 reduction was amplified among those whose closest friends at age 16 used cigarettes (OR = 0.50; 95% CI = 0.29, 0.87), consistent with peer effects moderating the policy's impact on young adult smoking., Conclusions: Tobacco-21 laws appear to reduce smoking among 18-20-year-olds who have ever tried cigarettes., (© 2019 Society for the Study of Addiction.)

Aims: To estimate young adults' preferences for cigarettes and e-cigarettes, and how preferences vary by policy-relevant factors. A related aim was to provide information on potential substitution/complementarity across cigarettes and e-cigarettes ahead of policy selection., Design: An online discrete choice experiment (DCE) in which respondents chose their preferred option among cigarettes, two types of e-cigarettes (disposable/reusable) and 'none'. Each cigarette-type was characterized by policy-relevant attributes: flavors, short-term health risks to self, secondhand smoke risks and price. A latent class model identified smoking types that respond differently to these., Setting: US tobacco market., Participants: A total of 2003 young adults (aged 18-22 years) who ever tried either cigarettes or e-cigarettes, recruited via the survey platform Qualtrics, matched to the 2015 National Health Interview Survey by age, gender, education and census region., Measurements: Respondents' DCE choices., Findings: Young adults fell into two broad categories. One latent group, termed 'prefer smoking group', preferred cigarettes and another, 'prefer vaping group', preferred e-cigarettes. The 'prefer smoking group' preferred lower prices and lower health harms more than other attributes. The 'prefer vaping group' valued these, although price less intensely, and valued health and fruit/candy flavors more., Conclusion: Banning all flavors in cigarettes and e-cigarettes might improve the health of young adults who ever tried either cigarettes or e-cigarettes. Young adult ever-triers might be deterred from smoking by increasing cigarette prices and encouraged to switch to e-cigarettes by reducing the health harms of e-cigarettes. Reducing health harms of e-cigarettes could also make the 'prefer vaping group' less likely to quit, resulting in increased health harm., (© 2019 Society for the Study of Addiction.)

Introduction: Although research suggests that youth e-cigarette experimentation is associated with later combustible cigarette experimentation, it is unclear how this relates to habitual smoking. This study assesses how minors' patterns of combustible cigarette and e-cigarette experimentation relate to habitual smoking at ages 18-21 years., Methods: Between November 2016 and May 2017, a cross-sectional, online survey of current and retrospective cigarette use was fielded among individuals aged 18-21 years who had tried combustible cigarettes or e-cigarettes (n=1,424). Logistic regressions tested how experimentation patterns prior to age 18 years related to two indicators of current habitual smoking: daily smoking and current established smoking (past 30-day use among those who had smoked ≥100 cigarettes)., Results: Respondents who first tried combustible cigarettes or e-cigarettes as minors (n=1,096) were more likely to be current established users (64%) than those who first experimented at ages 18-21 years (41%). Experimentation patterns in individuals aged <18 years beginning with combustible cigarettes were the most predictive of later smoking. Relative to those who first experimented at ages >17 years (n=328), trying only combustible cigarettes as a minor yielded a 175% increase in one's odds of being an established smoker (AOR=2.75, 95% CI=1.99, 3.79) and a 161% increase for daily smoking (AOR=2.61, 95% CI=1.75, 3.90). Trying combustibles and then e-cigarettes yielded sizable increases in both habitual smoking measures, whereas trying e-cigarettes before combustibles yielded smaller effects. Trying only e-cigarettes as a minor yielded a 78% decrease in both outcomes, relative to those who did not try either product as minors., Conclusions: Minors who tried combustible cigarettes were more likely to be habitual smokers at ages 18-21 years than those who tried e-cigarettes alone., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To provide the policy-relevant estimates of impacts of alternative flavour bans on preferences and demand for cigarettes and e-cigarettes in adult smokers and recent quitters., Methods: A best-best discrete choice experiment (DCE) is used to elicit smokers' and recent quitters' preferences for flavours, price, health impact and nicotine level in cigarettes and e-cigarettes. Choice of tobacco products and an opt-out option were examined. An efficient design yielded 36 choice sets. Exploded logit choice models were estimated. Flavour bans are modelled by restricting flavour coefficients in the estimated model., Setting and Participants: A sample of 2031 adult smokers and recent quitters was recruited to complete an online survey and DCE., Results: Current smokers and recent quitters, on average, prefer cigarettes and menthol cigarettes over flavoured e-cigarettes. However, there is substantial preference heterogeneity by younger adults (ages 18-25), race/ethnicity and respondents with higher education. Our predictions suggest that a ban on menthol cigarettes would produce the greatest reduction in the choice of cigarettes (-5.2%), but with an accompanying increase in e-cigarettes use (3.8%). In contrast, banning flavours in e-cigarettes, while allowing menthol in cigarettes would result in the greatest increase in the selection of cigarettes (8.3%), and a decline in the use of e-cigarettes (-11.1%). A ban on all flavours, but tobacco in both products would increase 'opting-out' the most (5.2%) but would also increase choice of cigarettes (2.7%) and decrease choice of e-cigarettes (-7.9%)., Conclusions: A ban on flavoured e-cigarettes alone would likely increase the choice of cigarettes in smokers, arguably the more harmful way of obtaining nicotine, whereas a ban on menthol cigarettes alone would likely be more effective in reducing the choice of cigarettes. A ban on all flavours in both products would likely reduce the smoking/vaping rates, but the use of cigarettes would be higher than in the status quo. Policy-makers should use these results to guide the choice of flavour bans in light of their stance on the potential health impacts both products., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Smoking is the most preventable cause of death, thus justifying efforts to effectively motivate quitting. We compared the effectiveness of financial versus health messages to motivate smoking cessation. Low-income individuals disproportionately smoke and, given their greater income constraints, we hypothesized that making financial costs of smoking more salient would encourage more smokers to try quitting. Further, we predicted that financial messages would be stronger in financial settings where pecuniary constraints are most salient., Methods: We conducted a field study in low-income areas of New Haven, Connecticut using brochures with separate health vs. financial messages to motivate smoking cessation. Displays were rotated among community settings-check-cashing, health clinics, and grocery stores. We randomized brochure displays with gain-framed cessation messages across locations., Results: Our predictions were confirmed. Financial messages attracted significantly more attention than health messages, especially in financial settings., Conclusions: These findings suggest that greater emphasis on the financial gains to quitting and use of financial settings to provide cessation messages may be more effective in motivating quitting. Importantly, use of financial settings could open new, non-medical venues for encouraging cessation. Encouraging quitting could improve health, enhance spending power of low-income smokers, and reduce health disparities in both health and purchasing power., (© 2013.)

Occupational choice is a significant input into workers' health investments, operating in a manner that can be either health-promoting or health-depreciating. Recent studies have highlighted the potential importance of initial occupational choice on subsequent outcomes pertaining to morbidity. This study is the first to assess the existence and strength of a causal relationship between initial occupational choice at labor entry and subsequent health behaviors and habits. We utilize the Panel Study of Income Dynamics to analyze the effect of first occupation, as identified by industry category and blue collar work, on subsequent health outcomes relating to obesity, alcohol misuse, smoking, and physical activity in 2005. Our findings suggest blue collar work early in life is associated with increased probabilities of obesity, at-risk alcohol consumption, and smoking, and increased physical activity later in life, although effects may be masked by unobserved heterogeneity. The weight of the evidence bearing from various methodologies, which account for non-random unobserved selection, indicates that at least part of this effect is consistent with a causal interpretation. These estimates also underscore the potential durable impact of early labor market experiences on later health.

Context: American obesity rates continue to escalate, but an effective policy response remains elusive. Specific changes to the Supplemental Nutrition Assistance Program (SNAP) have been proposed as one way to improve nutrition and combat obesity among lower-income populations. While current SNAP proposals hold promise, some important challenges still remain., Methods: We discuss the four most common recommendations for changes to SNAP and their benefits and limitations. We then propose three new delivery options for SNAP that take advantage of behavioral economic insights and encourage the selection of healthy foods., Findings: Although the existing proposals could help SNAP recipients, they often do not address some important behavioral impediments to buying healthy foods. We believe that behavioral economics can be used to design alternative policies with several advantages, although we recognize and discuss some of their limitations. The first proposal rewards healthy purchases with more SNAP funds and provides an additional incentive to maintain healthier shopping patterns. The second proposal uses the opportunity to win prizes to reward healthy food choices, and the prizes further support healthier habits. The final proposal simplifies healthy food purchases by allowing individuals to commit their SNAP benefits to more nutritious selections in advance., Conclusions: Reforming the delivery structure of SNAP's benefits could help improve nutrition, weight, and overall health of lower-income individuals. We advocate for more and diverse SNAP proposals, which should be tested and, possibly, combined. Their implementation, however, would require political will, administrative capacity, and funding., (© 2013 Milbank Memorial Fund.)

This paper estimates the price elasticity of demand for alcohol using Health and Retirement Study data. To account for unobserved heterogeneity in price responsiveness, we use finite mixture models. We recover two latent groups, one is significantly responsive to price, but the other is unresponsive. The group with greater responsiveness is disadvantaged in multiple domains, including health, financial resources, education and perhaps even planning abilities. These results have policy implications. The unresponsive group drinks more heavily, suggesting that a higher tax would fail to curb the negative alcohol-related externalities. In contrast, the more disadvantaged group is more responsive to price, thus suffering greater deadweight loss, yet this group consumes fewer drinks per day and might be less likely to impose negative externalities., (Copyright © 2011 John Wiley & Sons, Ltd.)

Smoking and drinking are critical problems in adolescence that have long-term adverse impacts on health and socio-economic factors. We examine the extent to which family stresses influence the timing of initiation of smoking and drinking. Using national panel data from the National Educational Longitudinal Study (NELS) we capitalize on the survey design and use school-level fixed effects that control for the local environments, including prices of cigarettes and alcohol. In addition, we narrow our control group to classmates who will experience a similar stressor in the future. We find that a composite measure of family stressors when young increases the likelihood of initiating tobacco and alcohol use, with much of the impact attributable to parental divorce. In our baseline estimates, the composite stress measure is associated with a 30% increase in the likelihood of smoking and a 20% increase in drinking. When we control for multiple sources of confounding, the impact shrinks and remains significant for smoking but not for drinking. We conclude that studies which do not control for confounding are likely to significantly overestimate the impact of family stress on substance use. Our approach helps to move the literature forward by separating causal results from spurious associations.

We examine whether the job characteristics of physical demands and environmental conditions affect individual's health. Five-year cumulative measures of these job characteristics are used to reflect findings in the biological and physiological literature that indicate that cumulative exposure to hazards and stresses harms health. To create our analytic sample, we merge job characteristics from the Dictionary of Occupational Titles with the PSID data set. We control for early and also lagged health measures and a set of pre-determined characteristics to try to address concerns that individuals self-select into jobs. Our results indicate that individuals who work in jobs with the 'worst' conditions experience declines in their health, though this effect varies by demographic group. We also find some evidence that job characteristics are more detrimental to the health of females and older workers. Finally, we report suggestive evidence that earned income, a job characteristic, partially cushions the health impact of physical demands and harsh environmental conditions for workers. These results are robust to inclusion of occupation fixed effects., (Copyright © 2010 John Wiley & Sons, Ltd.)

This paper examines the impact of job loss due to business closings on body mass index (BMI) and alcohol consumption. We suggest that the ambiguous findings in the extant literature may be due in part to unobserved heterogeneity in response and in part due to an overly broad measure of job loss that is partially endogenous (e.g., layoffs). We improve upon this literature using: exogenously determined business closings, a sophisticated estimation approach (finite mixture models) to deal with complex heterogeneity, and national, longitudinal data from the Health and Retirement Study. For both alcohol consumption and BMI, we find evidence that individuals who are more likely to respond to job loss by increasing unhealthy behaviors are already in the problematic range for these behaviors before losing their jobs. These results suggest the health effects of job loss could be concentrated among "at risk" individuals and could lead to negative outcomes for the individuals, their families, and society at large., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objectives: This paper examines whether retirement differentially affects body mass index (BMI) patterns by occupation; occupation embodies differences in on-the-job physical demands as well as socioeconomic characteristics that could lead to variation in post-retirement BMI., Methods: We use 12 years of national data from the US and hierarchical linear models to compare BMI trajectories among four broad occupational classes., Results: We find that those in service and other blue-collar occupations have significant increases in the slopes of their BMI trajectories after retirement, whereas participants in white-collar occupations exhibit no change. This may be due to differences in the physical requirements across blue and white collar jobs or differences in health habits post-retirement., Conclusions: Retirement may provide an opportunity to help prevent obesity in older individuals, especially blue collar workers.

Using a rich, recent, and nationally representative longitudinal survey specifically designed to examine alcohol use and associated problems, we investigate the effects of alcohol misuse on a series of understudied and perhaps less common employment problems. Such problems include being fired or laid off from a job, sustained unemployment, and conflicts with a supervisor and/or co-worker. After controlling for time-invariant omitted variables via fixed effects estimation, we find evidence that three measures of alcohol misuse are significantly related to employment problems. The results offer new information on the potential adverse labor market effects of alcohol misuse and shed light on potential mechanisms through which alcohol misuse may impact intensive labor supply and/or wages.

Many treatment programs have adopted or are considering adopting evidence-based treatments (EBTs). When a program evaluates whether to adopt a new intervention, it must consider program objectives, operational goals, and costs. This article examines cost concepts, cost estimation, and use of cost information to make the final decision on whether to adopt an EBT. Cost categories, including variable and fixed, accounting and opportunity, and costs borne by patients and others, are defined and illustrated using the example of expenditures for contingency management. Ultimately, cost is one consideration in the overall determination of whether implementing an EBT is the best use of a program's resources.

Job-related stress might affect smoking behavior because smoking may relieve stress and stress can make individuals more present-focused. Alternatively, individuals may both self-select into stressful jobs and choose to smoke based on unobserved factors. We use data from the Health and Retirement Study to examine how job stress affects the probability that smokers quit and the number of cigarettes smoked for current smokers. To address the potential endogeneity of job stress based on time invariant factors, we include individual fixed effects, which control for factors such as ability to handle stress. Occupational fixed effects are also included to control for occupational characteristics other than stress; time dummies control for the secular decline in smoking rates. Using a sample of people who smoked in the previous wave, we find that job stress is positively related to continuing to smoke among recent smokers. The results indicate that the key impact of stress is on the extensive margin of smoking, as opposed to the number of cigarettes smoked.

Aims of the Study: In this study, we explore whether ex ante work expectations, conditional on work force status at age 62, affect self-reported depressive symptoms at age 62., Methods: Our sample includes 4,387 participants of the Health and Retirement Study, a national longitudinal survey of individuals born between 1931 and 1941, and their spouses. The sample is composed of workers who were less than 62 years of age at the study baseline (1992), and who had reached age 62 by the current study endpoint (2004). This sample enables comparison of realized work status with prior expectations. We estimate the impact of expected work status on self-reported depressive symptoms using negative binomial and logistic regression methods. Sex-stratified regressions are estimated according to full-time work status at age 62. The primary outcome is a summary measure of self-reported depressive symptoms based on a short form of the Center for Epidemiologic Studies-Depression (CES-D) scale. The explanatory variable of interest is the subjective probability of working full-time at the age of 62, reported by participants at the 1992 HRS baseline. We control for baseline socioeconomic and demographic variables as well as life events and changes in macroeconomic conditions that occur within the study timeframe., Results: Among participants who were not working full time at age 62, we find that men who provided a higher ex ante likelihood of full-time employment at 62 had significantly worse self-reported depressive symptoms than men who provided a lower ex ante likelihood. A similar effect was not found for women. Among participants who were working full time at age 62, we do not find a statistical relationship between ex ante expectations and age-62 self-reported depressive symptoms, for either men or women., Discussion: The results suggest that an earlier-than-anticipated work exit is detrimental to mental health for men nearing normal retirement age. Previous research has demonstrated that stress is a causal factor in depression, and a premature labor force departure, which is inconsistent with an individual's cognitive judgment of a suitably timed exit from work, is a psychologically stressful transition that could realistically induce depression. This may be especially true of men, who in this cohort, have stronger labor force attachment than women and tend to define their roles by their occupation. The advantages of the study include nationally representative data, a baseline depression control that circumscribes the effect of endogeneity, and a reasonably long follow-up. Despite our efforts to infer causality, unmeasured factors may account for part of the observed relationship. IMPLICATIONS FOR HEALTH POLICY AND RESEARCH: Depression is a disease that, if untreated, may have serious consequences for behavioral, medical, and social well-being. Our results suggest that further research should aim to estimate the magnitude of clinically severe and mild depression in populations of those who retire earlier than expected, especially for men. Such information could help health care planners and policy makers to direct resources to the mental health needs of men who retire prematurely.

The cost of providing and receiving treatment for opioid dependence can determine its adoption. To compare the cost of clinic-based methadone (MC, n=23), office-based methadone (MO, n=21), and office-based buprenorphine (BO, n=34) we performed an analysis of treatment and patient costs over 6 months of maintenance in patients who had previously been stabilized for at least 1 year. We performed statistical comparisons using ANOVA and chi-square tests and performed a sensitivity analysis varying cost estimates and intensity of clinical contact. The cost of providing 1 month of treatment per patient was $147 (MC), $220 (MO) and $336 (BO) (p<0.001). Mean monthly medication cost was $93 (MC), $86 (MO) and $257 (BO) (p<0.001). The cost to patients was $92 (MC), $63 (MO) and $38 (BO) (p=0.102). Sensitivity analyses, varying cost estimates and clinical contact, result in total monthly costs of $117 to $183 (MC), $149 to $279 (MO), $292 to $499 (BO). Monthly patient costs were $84 to $133 (MC), $55 to $105 (MO) and $34 to $65 (BO). We conclude that providing clinic-based methadone is least expensive. The price of buprenorphine accounts for a major portion of the difference in costs. For patients, office-based treatment may be less expensive.

Congress is considering enactment of comprehensive parity legislation. The intent of parity is to equalize private coverage of behavioral and general medical care, thereby improving efficiency and fairness in insurance markets. One issue is whether to extend parity to substance abuse (SA) benefits. In the past, inclusion of substance abuse has been a hurdle to passage of parity. We examine the politics of SA parity, compare coverage trends for substance abuse and mental health, and assess the rationale for equalizing benefits. We conclude that the justification for SA parity is as compelling as it is for mental health parity.

This study determined whether, and by how much, the cost-effectiveness of contingency management (CM) varied across the eight clinics in the National Institute on Drug Abuse Clinical Trials Network MIEDAR trial. Incremental costs, incremental outcomes, and incremental cost-effectiveness ratios (ICERs) of CM compared to usual care were calculated, compared and contrasted for each of the clinics. Results showed that the incremental cost of using CM compared to usual care varied by a factor of 1.9 across the clinics, ranging from an additional $306 to an additional $582 per patient. The effect of CM on the longest duration of continuous stimulant abstinence (LDA) varied by a factor of 8.0 across the clinics, ranging from an additional 0.5 to an additional 4.0 weeks. The ICERs for the LDA varied by a factor of 4.6 across the clinics, ranging from $145 to $666. These results show that the cost-effectiveness of CM varied widely among the clinics in the MIEDAR trial. Future research should focus on identifying the sources of this variation, perhaps by identifying clinic-level best practices and/or identifying those subgroups of patients that respond the most cost-effectively, with the ultimate goal of improving the cost-effectiveness of CM overall.

Context: Second-generation antipsychotics (SGAs) are prescribed for psychosis, aggression, and agitation in Alzheimer disease (AD)., Objective: To conduct a cost-benefit analysis of SGAs and placebo (taken to represent a "watchful waiting" treatment strategy) for psychosis and aggression in outpatients with AD., Design: Randomized placebo-controlled trial of alternative SGA initiation strategies., Setting: Forty-two outpatient clinics., Participants: Outpatients with AD and psychosis, aggression, or agitation (N = 421). Intervention Participants were randomly assigned to treatment with olanzapine, quetiapine fumarate, risperidone, or placebo with the option of double-blind rerandomization to another antipsychotic or citalopram hydrobromide or open treatment over 9 months., Main Outcome Measures: Monthly interviews documented health service use and costs. The economic perspective addressed total health care and medication costs. Costs of study drugs were estimated from wholesale prices with adjustment for discounts and rebates. Quality-adjusted life-years (QALYs) were assessed with the Health Utilities Index Mark 3 and were supplemented with measures of functioning, activities of daily living, and quality of life. Primary analyses were conducted using all available data. Secondary analyses excluded observations after the first medication change (ie, phase 1 only). Cost-benefit analysis was conducted using the net health benefits approach in a sensitivity analysis in which QALYs were valued at $50,000 per year and $100,000 per year., Results: Average total health costs, including medications, were significantly lower for placebo than for SGAs, by $50 to $100 per month. There were no differences between treatments in QALYs or other measures of function. Phase 1-only analyses were broadly similar. Net-benefit analysis showed greater net health benefits for placebo as compared with other treatments, with probabilities ranging from 50% to 90%., Conclusions: There were no differences in measures of effectiveness between initiation of active treatments or placebo (which represented watchful waiting) but the placebo group had significantly lower health care costs., Trial Registration: clinicaltrials.gov Identifier: NCT00015548.

Aim: To determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is cost-effective., Design: A cost-effectiveness study of a multi-site clinical trial. Data on the outcome measures came from the original effectiveness trial. Cost data were gathered by clinic survey specifically for this cost-effectiveness analysis., Setting: Six methadone maintenance community clinics participating in the National Drug Abuse Treatment Clinical Trials Network., Participants: Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the UC condition and 198 in the CM condition. Participants were randomized at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample., Intervention: Prize-based contingency management added to usual care., Measurements: Longest duration of abstinence (LDA), number of stimulant-negative urine samples and costs of treatment., Findings: Compared to usual care, the incremental cost of using prize-based CM to lengthen the LDA by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117)., Conclusions: By comparing this study to a companion study, we found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics.

Aim: To analyze data from a randomized clinical trial to determine the cost-effectiveness of using contingency management (CM) and motivational/skills building therapy (motivational enhancement therapy/cognitive-behavioral therapy: MET/CBT) to treat young adults with marijuana dependence. PARTICIPANTS, DESIGN AND MEASUREMENTS: A total of 136 marijuana-dependent young adults, all referred by the criminal justice system, were randomized to one of four treatment conditions: MET/CBT with CM, MET/CBT without CM, drug counseling (DC) with CM and DC without CM. Patient outcome measures include the longest duration of confirmed marijuana abstinence (LDA) during treatment and the total number of marijuana-free urine specimens provided during treatment. Costs were collected retrospectively from the provider and include the costs of therapy, patient drug testing, and those associated with the incentives component (value of vouchers, time to administer the voucher system)., Setting: Out-patient substance abuse clinic in New Haven, Connecticut, USA., Findings: Which treatment is the most cost-effective depends on the threshold values of an additional week of LDA or an additional marijuana-free urine specimen. For example, the most effective treatment, MET/CBT with CM, was also the most cost-effective treatment at the highest threshold values, while the least effective treatment, DC, was the most cost-effective at the lowest values. Because consensus threshold values for these patient outcomes do not exist, results are presented showing the ranges of values over which each treatment would be considered cost-effective compared to the others. Acceptability curves are presented to show the decision uncertainty associated with these ranges. The results are shown to be robust to (i) sensitivity analyses on several key cost parameters and (ii) patient outcomes measured during the 6-month follow-up period., Conclusions: This study uses incremental cost-effectiveness ratios and acceptability curves to shed light on the relative cost-effectiveness of four interventions for treating young adults with marijuana dependence. Given the relatively small and specialized nature of our study sample, and the fact that we examined a CM procedure with a single reinforcement schedule, additional studies are warranted to determine the reliability and generalizability of our results both to alternative marijuana-using populations and to CM procedures with alternative incentive parameters. Nevertheless, the relative durability of effects of MET/CBT compared to DC through the 6-month follow-up, and its cost-effectiveness over a comparatively wide range of threshold values, underscores the promise of this approach.

Objective: To evaluate the cost-effectiveness of a prize-based intervention as an addition to usual care for stimulant abusers., Methods: This cost-effectiveness analysis is based on a randomized clinical trial implemented within the National Drug Abuse Treatment Clinical Trials Network. The trial was conducted at eight community-based outpatient psychosocial drug abuse treatment clinics. Four hundred and fifteen stimulant abusers were assigned to usual care (N=206) or usual care plus abstinence-based incentives (N=209) for 12 weeks. Participants randomized to the incentive condition earned the chance to draw for prizes for submitting substance negative samples; the number of draws earned increased with continuous abstinence time. Incremental cost-effectiveness ratios were estimated to compare prize-based incentives relative to usual care. The primary patient outcome was longest duration of confirmed stimulant abstinence (LDA). Unit costs were obtained via surveys administered at the eight participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Acceptability curves are presented to illustrate the uncertainty due to the sample and to provide policy relevant information., Results: The incremental cost to lengthen the LDA by 1 week was 258 US dollars (95% confidence interval, 191-401 US dollars). Sensitivity analyses on several key parameters show that this value ranges from 163 to 269 US dollars., Conclusions: Compared with the usual care group, the incentive group had significantly longer LDAs and significantly higher costs.

The goal of this study is to determine why recovering substance abuse counselors are paid less, on average and controlling for other factors, than nonrecovering substance abuse counselors. The data come from the 2002-2003 wave of the National Treatment Center Study and consist of 1,487 full-time counselors from nationally representative samples of public and private substance abuse treatment programs in the United States. We use ordinary least squares regression models to estimate the differential impacts of numerous personal and program characteristics on the self-reported annual salaries of recovering and nonrecovering counselors. We found that differential returns to a college degree explain the vast majority of the difference in pay by counselor recovery status. Compared to nonrecovering counselors, recovering counselors receive, on average and controlling for other factors, $2,580 less per year for a college degree. Several possible explanations for this result are discussed, including the possibility that recovering counselors are willing to accept lower pay as a reflection of their "calling" to this work.

Smoking is not only unhealthy, it is also expensive. Spending on tobacco could drive out other critical expenditures, including basic needs. This crowd out effect would be greatest in low-income countries, affecting not only the smoker but the rest of the family as well. The aim of this study is to examine the impact of tobacco spending on household expenditure patterns in rural China. China is a low-income country with a high prevalence of smoking, especially among men. The data, a sample of 4538 households, are from a household survey conducted in six townships in two provinces in rural China. Fractional Logit (Flogit) model is used as the estimation method. We estimate the relationship between tobacco spending and spending on 17 other categories, controlling for socio-economic and demographic characteristics of the household. The results indicate that spending on tobacco affects human capital investment (e.g. education and health), future farming productivity (e.g. farming equipment and seeds), and financial security (e.g. saving and insurance). Smokers also tend to spend more on alcohol, thus exacerbating the impact of addictive substances on spending on basic needs. Smoking expenses can harm other family members by reducing expenditures on basic needs such as foods, utilities, and durable goods consumption. Thus smoking can have important intra-family distributional impacts.

Objective: To extend our previous research by determining whether, and how, the impact of managed care (MC) on substance abuse treatment (SAT) services differs by facility ownership., Data Sources: The 2000 National Survey of Substance Abuse Treatment Services, which is designed to collect data on service offerings and other characteristics of SAT facilities in the U.S. These data are merged with data from the 2002 Area Resource File, a county-specific database containing information on population and MC activity. We use data on 10,513 facilities, virtually a census of all SAT facilities., Study Design: For each facility ownership type (for-profit [FP], not-for-profit [NFP], public), we estimate the impact of MC on the number and types of SAT services offered. We use instrumental variables techniques that account for possible endogeneity between facilities' involvement in MC and service offerings., Principal Findings: We find that the impact of MC on SAT service offerings differs in magnitude and direction by facility ownership. On average, MC causes FPs to offer approximately four additional services, causes publics to offer approximately four fewer services, and has no impact on the number of services offered by NFPs. The differential impact of MC on FPs and publics appears to be concentrated in therapy/counseling, medical testing, and transitional services., Conclusion: Our findings raise policy concerns that MC may reduce the quality of care provided by public SAT facilities by limiting the range of services offered. On the other hand, we find that FP clinics increase their range of services. One explanation is that MC results in standardization of service offerings across facilities of different ownership type. Further research is needed to better understand both the specific mechanisms of MC on SAT and the net impact on society.

Background: Studies have found important effects of poor mental health on labor market outcomes. The positive association between poor mental health and smoking has also been documented. This is the first study to document the separate and interactive impacts of smoking and mental health on wages., Aim: The primary aim of this study is to analyze the effect of poor mental health on wages while controlling for smoking status, and the interaction of poor mental health and smoking. We conduct separate regressions by gender., Methodology: We use data from the Community Tracking Survey for years 1996, 1998 and 2000. This survey interviews 60,000 people per cycle in the United States and collects detailed information on mental health status, smoking history and labor market outcomes. We use a two-step regression procedure to adjust for the fact that smoking and poor mental health may affect the labor market participation decision as well as wages. Separate regressions are estimated for men and women., Results and Discussion: Our results confirm that poor mental health is negatively associated with wages, as is current smoking, controlling for other factors. The impact of poor mental health is associated with an almost 8% reduction in wages for males and a bit more than a 4% decline for women in our most basic specification. We add to the literature by finding that the impact of poor mental health varies substantially by smoking status for males. Men who are in both poor mental health and who smoke have the largest associated reduction (-16.3%) in wage rates, while the interaction between poor mental health and smoking is insignificant for women., Limitations: While the data set has rich detail on smoking history and information on mental health, the data set lacks information on why former smokers quit and diagnosis of mental health disorders. The complex relationships among wages, mental health, and smoking also hinder determination of causality., Conclusions and Implications: Our findings suggest that both smoking and mental health are important factors in the determinations of wages and that the impact of mental health on wage rates varies by smoking status, at least for males. Our findings suggest that those who both smoke and have mental health problems, especially males, have the greatest productivity losses and are thus in the greatest need of interventions that address both issues jointly., Future Research: Further economics research should address the difficult issue of the potential endogeneity of mental health, smoking, and their interactions in regressions of wages. Clinical and worksite research could be aimed at determining those work environments and treatments that are effective in helping those with mental health problems who smoke to become more productive.

This article identifies and measures the key correlates of substance abuse treatment (SAT) counselor salaries. The data come from the 2002-2003 wave of the National Treatment Center Study that consists of approximately 1,500 full-time counselors from nationally representative samples of public and private SAT facilities. We used interval regression models to estimate the relationship between annual salary and numerous counselor and organizational characteristics. We found that counselor characteristics associated with annual salary include education, tenure in the SAT field, licensure, race, recovery status, and administrative responsibilities above and beyond duties as a full-time counselor. Organizational characteristics associated with counselor salary include accreditation status, hospital ownership, and the population density of the county where the facility is located. Taken together, these factors explain approximately 50% of the total variation in SAT counselor salaries.

Aims: To assess the impact of involuntary job loss due to plant closure or layoff on relapse to smoking and smoking intensity among older workers. DESIGN, PARTICIPANTS, SAMPLE: Data come from the Health and Retirement Study, a nationally representative survey of older Americans aged 51-61 in 1991 followed every 2 years beginning in 1992. The 3052 participants who were working at the initial wave and had any history of smoking comprise the main sample., Methods: Primary outcomes are smoking relapse at wave 2 (1994) among baseline former smokers, and smoking quantity at wave 2 among baseline current smokers. As reported at the wave 2 follow-up, 6.8% of the sample experienced an involuntary job loss between waves 1 and 2., Findings: Older workers have over two times greater odds of relapse subsequent to involuntary job loss than those who did not. Further, those who were current smokers prior to displacement that did not obtain new employment were found to be smoking more cigarettes, on average, post-job loss., Conclusions: The stress of job loss, along with other significant changes associated with leaving one's job, which would tend to increase cigarette consumption, must outweigh the financial hardship which would tend to reduce consumption. This highlights job loss as an important health risk factor for older smokers.

The number and type of services offered at substance abuse treatment (SAT) facilities are important aspects of the quality of care. Managed care (MC) is a growing presence in SAT and has been shown to affect the provision of treatment. We expand on earlier work and examine the impact of managed care on the number and type of services offered by methadone maintenance (MM) and drug-free (DF) outpatient treatment facilities. We use the econometric technique of instrumental variables to address the issue of endogeneity of MC and service offerings, thereby allowing a causal interpretation of results. Using data from the 2000 National Survey of Substance Abuse Treatment Services, we find that MC significantly increases the total number of services offered in MM outpatient facilities by four, yet decreases the number by two in DF outpatient facilities. We also show how the impact on specific services differs by modality and provide explanations for our findings.

Objective: This study examined the impact of smoking, quitting, and time since quit on absences from work., Methods: Data from the nationally representative Tobacco Use Supplements of the 1992/93, 1995/96, and 1998/99 Current Population Surveys were used. The study included full time workers aged between 18-64 years, yielding a sample size of 383 778 workers. A binary indicator of absence due to sickness in the last week was analysed as a function of smoking status including time since quit for former smokers. Extensive demographic variables were included as controls in all models., Results: In initial comparisons between current and former smokers, smoking increased absences, but quitting did not reduce them. However, when length of time since quit was examined, it was discovered that those who quit within the last year, and especially the last three months, had a much greater probability of absences than did current smokers. As the time since quitting increased, absences returned to a rate somewhere between that of never and current smokers. Interactions between health and smoking status significantly improved the fit of the model., Conclusions: Smokers who quit reduced their absences over time but increase their absences immediately after quitting. Quitting ill may account for some but not all of this short run impact.

This article proposes a method of calculating a practical index of improvement for conducting a cost-effectiveness analysis of substance abuse treatment. While the methodology of cost-effectiveness analysis necessitates the use of a single outcome measure, substance abuse treatment can produce multiple, important outcomes that must be considered in policy decisions about funding and alternative treatments. Thus, there is a need to aggregate the variety of outcomes from substance abuse treatment into a single index. The proposed index is a preference-weighted sum of outcomes using data from the Addiction Severity Index. The methodology and use of the index for conducting a cost-effectiveness analysis are illustrated using Addiction Severity Index data from a controlled quasi-experimental field study of case management.

Many substance abuse treatment (SAT) facilities offer programs designed specifically for special populations such as women, adolescents, gays/lesbians and others. Previous research shows that there are specific services that are integral to the successful treatment of these populations (e.g., family therapy for adolescents, childcare and transportation assistance for women, and HIV testing and counseling for gays/lesbians). This study examines whether facilities that self-report having programs for special populations actually offer the recommended services. The data come from the 2000 National Survey of Substance Abuse Treatment Services, which contains information on service offerings, special programs and other characteristics for all SAT facilities in the USA. The results indicate that facilities with special programs are more likely to offer the recommended key services. However, often less than half of these facilities provide the key services. There are consistent differences by ownership status, with for-profit facilities less likely to offer many of the key services.

Converging evidence suggests that disulfiram is a promising treatment for cocaine dependence. We study the cost-effectiveness of providing disulfiram to methadone-maintained opioid addicts in a randomized clinical trial setting. Our economic evaluation is based on a double blind clinical trial in which 67 cocaine-dependent methadone-maintained opioid-dependent subjects were randomized to get the additional treatment of disulfiram or placebo in a 12-week trial. Outcome measures used are the number of days of cocaine use and grams of cocaine per week. Cost measures used are the cost of providing standard methadone treatment and the incremental cost of adding disulfiram to the standard treatment. Cost measures of standard and disulfiram-enhanced treatment were collected retrospectively from the provider. Results from this cost-effectiveness analysis imply that, even though disulfiram increases slightly the cost of methadone treatment, its increase in effectiveness may be important enough to warrant its addition for treating cocaine dependence in methadone-maintained opiate addicts.

This paper identifies and illustrates the challenges of conducting cost-effectiveness analysis (CEA) of addiction treatments given the multiple important outcomes of substance abuse treatment (SAT). Potential problems arise because CEA is intended primarily for single outcome programs, yet addiction treatment results in a variety of outcomes such as reduced drug use and crime and increased employment. Methodological principles, empirical examples, and practical advice are offered on how to conduct an economic evaluation given multiple outcomes. An empirical example is provided to illustrate some of the conflicts in cost-effectiveness (CE) ratios that may arise across the range of outcomes. The data are from the Philadelphia Target Cities quasi-experimental field study of standard versus "enhanced" (e.g. case management and added social services) drug treatment. Outcomes are derived from of the Addiction Severity Index (ASI), while cost data were collected and analyzed using the Drug Abuse Treatment Cost Analysis Program (DATCAP). While the results are illustrative only, they indicate that cost-effectiveness ratios for each of several different outcomes can produce conflicting implications. These findings suggest that multiple outcomes should be considered in any economic analysis of addiction treatments because focusing on a single outcome may lead to inadequate and possibly incorrect policy inferences. However, incorporating multiple outcomes into a CEA of addiction treatment is difficult. Cost-benefit analysis (CBA) may be a preferable and more appropriate approach in some cases.

Smoking is an expensive habit. Smoking households spend, on average, more than $US1000 annually on cigarettes. When a family member quits, in addition to the former smoker's improved long-term health, families benefit because savings from reduced cigarette expenditures can be allocated to other goods. For households in which some members continue to smoke, smoking expenditures crowd-out other purchases, which may affect other household members, as well as the smoker. We empirically analyse how expenditures on tobacco crowd-out consumption of other goods, estimating the patterns of substitution and complementarity between tobacco products and other categories of household expenditure. We use the Consumer Expenditure Survey data for the years 1995-2001, which we complement with regional price data and state cigarette prices. We estimate a consumer demand system that includes several main expenditure categories (cigarettes, food, alcohol, housing, apparel, transportation, medical care) and controls for socioeconomic variables and other sources of observable heterogeneity. Descriptive data indicate that, comparing smokers to nonsmokers, smokers spend less on housing. Results from the demand system indicate that as the price of cigarettes rises, households increase the quantity of food purchased, and, in some samples, reduce the quantity of apparel and housing purchased.

Background: Influenza vaccinations are currently advocated only for individuals over age 50. However, vaccination of all working-age people may be warranted based on reduced absenteeism from work., Objective: This study aims to quantify the association between lost workdays and influenza, controlling for other factors. A secondary aim of the study is to assess the net benefit of expanded vaccination in a workplace setting., Research Design: Multivariate regression analyses of the 1996 Medical Expenditure Panel Survey Household Component are used to estimate the number of workdays missed because of influenza-like illness (ILI) when controlling for other health, demographic, and employment factors. Mean productivity costs are measured in terms of absences from work and valued in dollar terms. The net benefit of influenza vaccination is estimated using a simple decision analysis., Subjects and Measures: Health, demographic, and employment data for employed individuals between the ages of 22 and 64 years are analyzed., Results: The average number of workdays missed due to ILI was 1.30 days, and the average work loss was valued at 137 US dollars per person. The vaccine strategy was not preferred in the baseline analysis; however, this result was sensitive to assumptions regarding the incidence of influenza, the cost of delivering the vaccine, and the productivity impact of worker absenteeism. Moreover, nonproductivity benefits of vaccination were omitted., Conclusions: The economic attractiveness of expanded investment in influenza vaccination hinges on employer- and population-specific assumptions. Our analysis provides a simple framework within which competing considerations of disease epidemiology, worker productivity, and economic cost may be weighed.