Brent Gibbons’s journal round-up for 10th February 2020

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Impact of comprehensive smoking bans on the health of infants and children. American Journal of Health Economics [RePEc] Published 15th January 2020

While debates on tobacco control policies have recently focused on the rising use of e-cigarettes and vaping devices, along with recent associated lung injuries in the U.S., there is still much to learn on the effectiveness of established tobacco control options. In the U.S., while strategies to increase cigarette taxes and to promote smoke-free public spaces have contributed to a decline in smoking prevalence, more stringent policies such as plain packaging, pictorial warning labels, and no point-of-sale advertising have generally not been implemented. Furthermore, comprehensive smoking bans that include restaurants, bars, and workplaces have only been implemented in approximately 60 percent of localities. This article fills an important gap in the evidence on comprehensive smoking bans, answering how this policy affects the health of children. It also provides interesting evidence on the effect of comprehensive smoking bans on smoking behavior in private residences.

There is ample evidence to support the conclusion that smoking bans reduce smoking prevalence and the exposure of nonsmoking adults to second-hand smoke. This reduced second-hand smoke exposure has been linked to reductions in related health conditions for adults, but has not been studied for infants and children. Of particular concern is that smoking bans may have the unintended ‘displacement’ effect of increasing smoking in private residences, potentially increasing exposure for some children and pregnant women.

For their analyses, the authors use nationally representative data from the US Vital Statistics Natality Data and the National Health Interview Survey (NHIS), coupled with detailed local and state tobacco policy data. The policy data allows the authors to look at partial smoking bans (e.g. limited smoking bans in bars and restaurants) versus comprehensive smoking bans, which are defined as 100 percent smoke-free environments in restaurants, bars, and workplaces in a locale. For their main analyses, a difference-in-difference model is used, comparing locales with comprehensive smoking bans to locales with no smoking bans; a counter factual of no smoking bans or partial bans is also used. Outcomes for infants are low birth weight and gestation, while smoke-related adverse health conditions (e.g. asthma) are used for children under 18.

Results support the conclusion that comprehensive smoking bans are linked to positive health effects for infants and children. The authors included local geographic fixed effects, controlled for excise taxes, and tested an impressive array of sensitivity analyses, all of which support the positive findings. For birth outcomes, the mechanism of effect is explored, using self-reported smoking status. The authors find that a majority of the birth outcome effects are likely due to pregnant mothers’ second-hand smoke exposure (80-85 percent), as opposed to a reduction in prenatal smoking. And regarding displacement concerns, the authors examine NHIS data and find no evidence that smoking bans were associated with displacement of smoking to private residences.

This paper is worth a deep dive. The authors have made an important contribution to the evidence on smoking bans, addressing a possible unintended consequence and adding further weight to arguments for extending comprehensive smoking bans nationwide in the U.S. The health implications are non-trivial, where impacts on birth outcomes alone “can prevent between approximately 1,100 and 1,750 low birth weight births among low-educated mothers, resulting in economic cost savings of about $71-111 million annually.”

Europeans’ willingness to pay for ending homelessness: a contingent valuation study. Social Science & Medicine Published 15th January 2020

Housing First (HF) is a social program that originates from a program in the U.S. to address homelessness in Los Angeles. Over time, it has been adapted particularly for individuals with unstable housing who have long-term behavioral health disorders, including mental health and substance use disorders. Similar to other community mental health services, HF has incorporated a philosophy of not requiring conditions before providing services. For example, with supported employment services, to help those with persistent behavioral health disorders gain employment, the currently accepted approach is to ‘place’ individuals in jobs and then provide training and other support; this is opposed to traditional models of ‘train, then place’. Similarly, for housing, the philosophy is to provide housing first, with various wraparound supports available, whether those wraparound services are accepted or not, and whether the person has refrained from substance use or not. The model is based on the logic that without stable housing, other health and social services will be less effective. It is also based on the assertion that stable housing is a basic human right.

Evidence for HF has generally supported its advantage over more traditional policies, especially in its effectiveness in improving stable housing. Other cost offsets have been reported, including health service use reductions, however, the literature is more inconclusive on the existence and amount of cost offsets. The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified HF as an evidence-based model and a number of countries, including the U.S., Canada, and several European countries, have begun incorporating HF into their homelessness policies. Yet the cost effectiveness of HF is not firmly addressed in the literature. At present, results appear favorable towards HF in comparison to other housing policies, though there are considerable difficulties in HF CEAs, most notably that there are multiple measures of effectiveness (e.g. stable housing days and QALYs). More research needs to be done to better establish the cost-effectiveness of HF.

I’ve chosen to highlight this background because Loubiere et al., in this article, have pushed a large contingent valuation (CV) study to assess willingness to pay (WTP) for HF, which the title implies is commensurate with “ending homelessness”. Contingent valuation is generally accepted as one method for valuing resources where no market is available, though not without considerable past criticism. Discrete choice experiments are favored (though not with their own criticism), but the authors decided on CV as the survey was embedded in a longer questionnaire. The study is aimed at policy makers who must take into account broader public preferences for either increased taxation or for a shifting of resources. The intention is laudable in the respect that it attempts to highlight how much the average person would be willing to give up to not have homelessness exist in her country; this information may help policy makers to act. But more important, I would argue, is to have more definitive information on HF’s cost-effectiveness.

As far as the rigor of the study, I was disappointed to see that the survey was performed through telephone, which goes against recommendations to use personal interviews in CV. An iterative bidding process was used which helps to mitigate overvaluation, though there is still the threat of anchoring bias, which was not randomly allocated. There was limited description of what was conveyed to respondents, including what efficacy results were used for HF. This information is important to make appropriate sense of the results. Aside from other survey limitations such as acquiescence bias and non-response bias, the authors did attempt to deal with the issue of ‘protest’ answers by performing alternative analyses with and without protest answers, where protest answers were assigned a €0 value. WTP ranged from an average of €23 (€16 in Poland to €57 in Sweden) to €28 Euros. Analyses were also conducted to understand factors related to reported WTP. The results suggest that Europeans are supportive of reducing homelessness and will give up considerable hard earned cash toward this cause. This reader for one is not convinced. However, I would hope that policy makers, armed with better cost effectiveness research, could make policy decisions for a marginalized group, even without a more rigorous WTP estimate.

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  • Baltimore-raised, Singapore-based health economist, mental health advocate, jazz enthusiast

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