JAMA Health Forum最新文献

Importance: Research shows that Tobacco 21 (T21) policies with a minimum legal access age for tobacco products of 21 years reduce smoking, yet their impact varies across US states due to differences in smoking behaviors, mortality rates, and policy coverage.

Objective: To quantify potential reductions in smoking-attributable mortality associated with Tobacco 21 policies for each of the 50 states and Washington, DC.

Design, setting, and participants: The Cancer Intervention Surveillance and Modeling Network (CISNET) Tobacco Control Policy Model of smoking was used with detailed state-specific data on smoking initiation, smoking cessation and mortality rates as they vary by age, gender, and birth cohort for 50 US states and the District of Columbia. This was integrated with comprehensive data on T21 policy coverage at the local and state levels from 2005 to 2024, and then T21 policy effects from quasi-experimental studies were applied to simulate each state's experience of T21 policies, quantifying potential mortality reductions from 2005 to 2100.

Exposures: Cigarette smoking.

Main outcomes and measures: Estimated smoking-attributable deaths averted and life-years gained compared with a baseline scenario.

Results: Early statewide T21 adoption in California, combined with its large population, was associated with more than 27 000 premature deaths averted through 2100, whereas statewide implementation in Kentucky was associated with 15 000 averted premature deaths. In Massachusetts, T21 policies were associated with 8000 averted premature deaths, largely attributed to municipal T21 policies covering most residents. Wisconsin-lacking state or local policies-requires enforcement of federal T21 to prevent up to 10 000 premature deaths. Across the country, comprehensive enforcement of federal, state, and local T21 laws were associated with up to 526 000 premature deaths averted and 13.3 million life-years gained by 2100. Enforcement of only state and local policies was associated with 442 000 premature deaths averted.

Conclusions and relevance: This study found that early adoption and implementation of T21 policies maximizes potential premature mortality reductions. However, the strength of T21 policies and enforcement varies widely across states. Enforcement of the federal T21 law is critical in the 8 states without state-level T21 cigarette policies of their own.

Importance: More than one-quarter of US residents live in states or localities that restrict sales of flavored electronic nicotine delivery systems (ENDS), often as a means to reduce youth vaping. Yet, how these policies affect young adult vaping and smoking remains unclear.

Objective: To estimate the effects of ENDS flavor restrictions on ENDS use and cigarette smoking among young adults (age 18-29 years) in the US.

Design, participants, and setting: This quasi-experimental analysis used annual survey data from the 2016 to 2023 Behavioral Risk Factor Surveillance System (BRFSS), a series of nationally- and state-representative, repeated cross-sectional surveys of noninstitutionalized civilian adults in the US. Two-way fixed-effects specifications were estimated to assess how ENDS flavor restrictions affect young adults' use of ENDS and cigarettes. Analyses were adjusted for potential confounders including concurrent tobacco control policies, respondent demographic characteristics, and socioeconomic factors. Data analyses were conducted in November 2023 and repeated in October 2024 to incorporate newly released 2023 survey data.

Main outcomes and measures: Current and daily use of ENDS and of cigarettes as measured in the BRFSS.

Results: Balanced panel analyses of 242 154 individuals aged 18 to 29 years consistently found that state ENDS flavor restrictions were associated with statistically significant reductions in daily vaping and increases in daily cigarette smoking. Estimates were similar across robustness checks, with the main specification showing 3.6 (95% CI, -5.0 to -2.1) percentage point (ppt) reductions in daily vaping and 2.2 ppt increases in daily cigarette smoking (95% CI, 1.0 to 3.4) relative to changes in states without restrictions. These estimates are equivalent to an 80% reduction in daily vaping and 22% increase in daily smoking compared with 2018 mean rates.

Conclusions and relevance: The findings of this quasi-experimental analysis of BRFSS survey data indicate that state restrictions on flavored ENDS sales were associated with reduced vaping among young adults but may have unintentionally increased cigarette smoking, potentially offsetting public health gains. These findings suggest that alleviating the burden of tobacco-related disease will require regulatory strategies that balance reducing vaping with preventing increases in more lethal, combustible tobacco use.

Importance: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have changed clinical management of chronic kidney disease (CKD) and made populationwide screening for CKD a viable strategy. Optimal age of screening initiation has yet to be evaluated.

Objective: To compare the clinical benefits, costs, and cost-effectiveness of population-wide CKD screening at different initiation ages and screening frequencies.

Design, setting, and participants: This cost-effectiveness study used a previously published decision-analytic Markov cohort model that simulated progression of CKD among US adults from age 35 years and older and was calibrated to population-level data from the National Health and Nutrition Examination Survey (NHANES). Effectiveness of SGLT2 inhibitors was derived from the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial. Mortality, quality-of-life weights, and cost estimates were obtained from published cohort studies, randomized clinical trials, and US Centers for Medicare & Medicaid Services data. Analyses were performed from June 2023 through September 2024.

Exposures: One-time or periodic (every 10 or 5 years) screening for albuminuria, initiated at ages between 35 and 75 years, with and without addition of SGLT2 inhibitors to conventional CKD therapy (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers).

Main outcomes and measures: Cumulative incidence of kidney failure requiring kidney replacement therapy (KRT); life years, quality-adjusted life years (QALYs), lifetime health care costs (2024 US currency), and incremental cost-effectiveness ratios discounted at 3% annually.

Results: For those aged 35 years, starting screening at age 55 years, and continuing every 5 years through age 75 years, combined with SGLT2 inhibitors, decreased the cumulative incidence of kidney failure requiring KRT from 2.4% to 1.9%, increased life expectancy by 0.13 years, and cost $128 400 per QALY gained. Although initiation of screening every 5 years at age 35 or 45 years yielded greater gains in population-wide health benefits, these strategies cost more than $200 000 per additional QALY gained. The comparative values of starting screening at different ages were sensitive to the cost and effectiveness of SGLT2 inhibitors; if SGLT2 inhibitor prices drop due to patent expirations, screening at age 55 years continued to be cost-effective even if SGLT2 inhibitor effectiveness were 30% lower than in the base case.

Conclusions and relevance: This study found that, based on conventional benchmarks for cost-effectiveness in medicine, initiating population-wide CKD screening with SGLT2 inhibitors at age 55 years would be cost-effective.