On June 1, 2020, Massachusetts became the first state in the US to implement a comprehensive prohibition on all flavored tobacco products, including menthol cigarettes. My study for Reason Foundation revealed that cross-state trafficking led to a net increase in cigarette sales for the Massachusetts region after considering the rise in cigarette sales in surrounding states after the ban. 

Now, the medical literature also acknowledges that the increase in cigarette sales has manifested in increases in smoking for various populations, especially those the prohibition intended to target. Indeed, the letter’s authors specifically advise, “As the FDA plans to eliminate menthol as a characterizing flavor in cigarettes, interventions should address possible increases in cigarette smoking among Black females.”

According to Asare et al., the menthol cigarette ban in Massachusetts led to an 8.1% relative decrease in smoking among adults 25 years and older, with the prevalence of current cigarette use dropping from 13.0% in 2019 to 12.0% by 2021. Part of this decrease was due to a reported 56.8% relative decrease in smoking among black men. However, with a 58.6% relative increase in smoking among black women and an equal prevalence of smoking among both genders in 2019, the menthol cigarette ban led to a net increase in smoking among black adults in Massachusetts. 

The authors’ approach involved a difference-in-differences analysis, looking at whether the changes in smoking for various populations in Massachusetts differed from other states throughout the country after the menthol cigarette ban. Referencing individual-level data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, Asare et al. created state-level estimates for the prevalence of current smoking from 2017 to 2021. However, the significant percentage change estimates for the black population are suspicious. As a technical matter, the Centers for Disease Control and Prevention (CDC) instruct researchers to estimate prevalence from the BRFSS with survey weights in combination with strata and primary sampling units (PSUs). Still, the supplementary section makes no mention of strata or PSUs. Regardless, the observed net increase in smoking among black adults, instead of a significant decrease, considerably departs from what researchers expected.

These results undermine the saliency of tobacco flavor ban policies, especially menthol cigarette prohibitions. Like illicit drugs, the black market organizes to fill the void when regulated sellers can no longer legally provide products. In the case of Massachusetts, surrounding states, like New Hampshire, have a cigarette tax that is almost half of that in Massachusetts. This means that when the black market was able to organize, in many circumstances, it could buy cigarettes in New Hampshire and offer buyers in Massachusetts cigarettes at a lower price relative to the previous pre-menthol ban market, which increased access to cigarettes overall.

Much of the original motivation to pursue a menthol cigarette ban was to try to achieve “health equity,” which meant addressing disparities in health between black and white Americans. Although black adults and youth have historically smoked less than whites, the medical literature often reports that they “suffer disproportionately from tobacco-related diseases compared to non-Hispanic whites.” These observations have led influential public health institutions to advocate for menthol cigarette bans, hoping to reduce smoking in the black community further to improve health outcomes. 

But, with the flavor ban in Massachusetts leading to more cigarette sales in the region and an increase in smoking among black women, it seems clear that menthol prohibitions are ineffective mechanisms for improving public health in the black community. Instead, public health officials should promote safer alternatives to combustible cigarettes, such as e-cigarettes, which have proven effective in helping smokers quit.

The post Massachusetts menthol ban increased smoking among black women, research finds appeared first on Reason Foundation.

The ban has served as a test for what other states and municipalities might expect if they enact similar prohibitions on flavored tobacco products. Although officials often promote tobacco control policies as ways to protect public health, the unintended consequences of menthol cigarette bans on total cigarette sales have puzzled many public health officials and raised important questions about the effectiveness of the prohibitions.

In my analysis of the comprehensive flavored tobacco ban implemented in Massachusetts, the data show that the prohibition of menthol cigarettes was followed by millions of additional cigarette sales in the six-state region of Massachusetts and its bordering states. The year following the ban on menthol cigarette purchases saw 15 million fewer packs of menthol cigarettes sold than the year before the ban. However, approximately 22 million additional packs of nonmenthol cigarettes were sold in those states in the year after the flavor ban, leading to a net increase in cigarette sales.

In the 12-month period following the implementation of the comprehensive flavor ban in Massachusetts, the state sold 29.96 million fewer (22.24% less) cigarette packs compared to the prior year. However, a total of 33.3 million additional cigarette packs were sold during the same post-ban period in the counties that bordered Massachusetts in the states of Connecticut (3.05 million additional packs), New Hampshire (25.84 million), New York (1.04 million), Rhode Island (6.01 million), and Vermont (1.21 million). Thus, considering the change in cigarette sales in the entire six-state region, there was a net increase of 7.21 million additional cigarette packs sold in the 12 months after the menthol cigarette ban in Massachusetts, a 1.28% increase in cigarette sales compared to the prior 12-month period before the ban.

A paper by Samuel Asare et al. (2022) published in JAMA Internal Medicine publicized a reduction in cigarette sales in Massachusetts following the menthol cigarette ban but failed to include all but one of the bordering states in its analysis. Additionally, the paper analyzed Nielsen Retail Scanner data, which only represented approximately 30% of all US mass merchandiser sales volume that year. In contrast, the Management Science Associates Inc (MSAi) data in my analysis represents all cigarette distribution throughout the entire US.

In conclusion, policymakers must be careful about enacting prohibitions for a variety of reasons, including when the banned product is still available for sale in nearby municipalities. This is especially true when tax rates in neighboring states are relatively low. In 2020, the sales tax for cigarettes in New Hampshire ($1.78 per pack) was approximately half that of Massachusetts ($3.51 per pack), which further incentivized bulk purchases of cigarettes and allowed for a sizeable smuggling market for black market sellers after the flavored tobacco ban was implemented. 

With similar flavored tobacco prohibitions being proposed in states like Maryland, which currently has a cigarette sales tax of $3.75 a pack, policymakers should keep in mind that neighboring Virginia has a much-lower sales tax of $0.60 per pack and that the cross-border smuggling of cigarettes would inevitably follow a menthol cigarette prohibition in Maryland.

The data from Massachusetts and neighboring states show the menthol ban did not stop people from buying cigarettes, with sales increasing by seven million packs in the year after Massachusetts’ flavored tobacco ban. Massachusetts’ flavored tobacco ban primarily sent buyers to others states and illicit markets, so other cities and states should consider the real-world impacts of implementing similar prohibitions.

The post The effect of menthol bans on cigarette sales: Evidence from Massachusetts  appeared first on Reason Foundation.

Thank you for the opportunity to testify today. My name is Jacob James Rich, and I am a researcher at the Cleveland Clinic Center for Value-Based Care Research pursuing my Ph.D. at the Case Western Reserve University School of Medicine. I am also a health care policy analyst at Reason Foundation, a 501(c)3 nonprofit policy research organization. I write academic research on how to reduce tobacco use and was recently awarded Case Western’s Diversity, Equity, and Inclusion (DEI) award to pursue research that addresses health disparities among marginalized populations.

The potential regulation of flavored tobacco in the city of Columbus is designed to reduce tobacco use, particularly among communities of color. Given that rates of lung disease among black Americans are higher than other populations, even amid lower rates of historic tobacco use, pursuing interventions to reduce smoking rates in this population should be applauded. However, there is little evidence that comprehensive tobacco flavor bans significantly reduce rates of smoking among adults or youth, and the criminal justice implications of a menthol ban may, in fact, further exacerbate health disparities in the black community.

Policymakers should be concerned about the differential racial impact of this regulation. Menthol cigarettes are preferred by the black population. Therefore, a menthol cigarette ban would likely allow most white people to freely and legally continue to smoke their preferred cigarettes, while communities of color would need to either travel outside city limits or source from unlicensed cigarette providers. This could be disastrous, as it may increase police officer confrontations and increase the number of street sellers who are more likely to sell cigarettes to young people.

Additionally, in just about every way possible, nonflavored cigarettes cause much more harm in the United States than menthol cigarettes. First, more people smoke nonflavored cigarettes than menthol cigarettes — both adults and youth. Second, people who smoke menthol cigarettes tend to smoke fewer cigarettes a day. Given these considerations, nonflavored cigarettes are typically the more addictive product, so a true public health approach would prioritize controlling nonflavored cigarettes. It is also not clear that the regulation will even reduce smoking.

Case Study: Massachusetts Comprehensive Tobacco Flavor Ban

On June 1, 2020, Massachusetts implemented a tobacco flavor ban. I authored an analysis that compared cigarette sales in Massachusetts after the flavor ban to the year prior to the ban, finding millions of additional cigarette sales in and around Massachusetts when combined with its bordering states. It is true that menthol cigarette bans reduce cigarette sales locally. However, if surrounding localities have lower cigarette taxes — just like they did near Massachusetts and do near Columbus — total cigarette sales actually tend to increase as residents drive across borders and buy cigarette cartons in bulk.

Conclusion

In conclusion, flavor bans at the local level have little effect on public health and potentially disastrous consequences for communities of color. Massachusetts has already conducted multiple raids after implementing its flavor ban, mostly in communities of color. I urge the city of Columbus to collaborate with community members in determining an inclusive approach to improving health outcomes among its historically marginalized populations.

Thank you for your time and consideration.

The post Testimony: The negative impacts of Columbus’ proposed ban on flavored tobacco appeared first on Reason Foundation.

Figure 1. Drug Overdose Deaths by Substance

Source: Years 1999 to 2020 from CDC WONDER; Year 2021 reports preliminary data from NCHS.

Addiction in the United States has been dropping for the last 20 years (Figure 2). Opioid addiction, in particular, has been dropping for approximately 10 years. In 2002, 9.4 percent of Americans were addicted to a drug, including 0.7 percent of Americans addicted to opioids. In 2019, the last year measured with a comparable standard (DSM-IV), 7.4 percent of Americans were addicted to substances with 0.6 percent of those being addicted to opioids. Additionally, record levels of naloxone and addiction treatment medications are being distributed, which means more people received addiction treatment in 2021 than any other year in American history.

Figure 2. Addiction Rate (%) in the U.S. by Substance Over Time​​

Sources: Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health, SAMHSA; Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health, SAMHSA.

Fewer Americans are addicted to drugs and more of those who are addicted are receiving medication-assisted treatment for addiction, yet more people are dying from drug use. So, what is going on?

The reality is that drug addiction and drug-related deaths don’t have much of a relationship. Drug-related deaths are almost solely caused by the safety of the drug supply, which is made more dangerous by successful drug enforcement. 

Public health interventions like prescription drug monitoring programs (PDMPs), which have been implemented in recent years to reduce opioid prescribing—and have successfully reduced the numbers of opioids prescribed by doctors since 2012—have motivated more drug users to resort to the black market for their fix. And when law enforcement becomes more successful at seizing illegal drugs, traffickers increase the potency of their narcotics to evade detection.

For example, as the Drug Enforcement Administration (DEA) successfully seized increasing amounts of heroin between 2010 and 2014, they soon started to seize fentanyl instead in the years following. During this shift, overdoses by fentanyl replaced those caused by heroin, but at a higher rate. And now those with substance use disorder are dying at such a high rate that overdoses are spiking despite a shrinking population of regular drug users. That means addiction is dropping in the U.S., but our drug-enforcement policies are killing more drug users by driving them to potent, unregulated products like fentanyl.

Some media outlets are starting to better connect these relationships. U.S. News & World Report, for example, recently reported “Teen Overdose Deaths Have Soared, Even Though Drug Use Hasn’t,” which could have been written about most age groups in the U.S. Reason has written about this false relationship for decades. But if we are to finally address drug-related deaths in this country, we will need this insight to become common knowledge amongst policymakers, public health officials, and the public-at-large.

Lawmakers intentionally reduced the rates of legal opioid prescribing by doctors, but drug-related deaths in the United States continue to climb to unprecedented heights every single year. If the U.S. continues its failed drug war approach, Americans should, sadly, expect even more overdose deaths in the years to come, as black market drug producers will continue to have incentives to create more potent products. 

Americans can have fewer drug users or fewer drug overdoses, but it is unlikely to have both. Let’s hope that the country reconsiders its opioid policies and opts to be a humane society that leans towards more freedom and less death.

The post Over 100,000 died from drug overdoses in 2021 as public policy drives people to fentanyl appeared first on Reason Foundation.

Some Democrats in Congress claim the increased taxes would raise nearly $100 billion over the next 10 years and they plan to use the revenue to help fund their proposed $3.5 trillion reconciliation spending package. 

Although higher cigarette taxes can lead to less smoking, the economic and public health implications of such a tax increase would be complicated for states like West Virginia. To start, the Mountain State has one of the highest rates of poverty in the country and the burden of increased cigarette taxes would fall heavily upon the state’s low-income residents. A pack-a-day smoker in West Virginia is currently paying about $1,200 a year in cigarette taxes and doubling the federal tax would increase their burden by $392 a year. This would come on top of inflation, which has already reduced family income in the state by $1,000 this year according to Harvard economist Jason Furman, a former Obama administration chairman of the Council of Economic Advisors.

It seems the proposal would also contradict President Joe Biden’s campaign promise to not raise taxes on individuals making less than $400,000 a year. In fact, 72 percent of smokers come from lower socio-economic communities, according to the nonprofit anti-smoking group the Truth Initiative.

According to the latest National Survey on Drug Use and Health, in 2019 West Virginia had the highest rate of smoking in the country. Public health experts may argue that this is exactly why the state has the most to gain from a higher cigarette tax. While some smokers would quit due to the higher taxes, many would not and the tax would disproportionately affect West Virginia’s lower- and middle-income individuals. 

Furthermore, by taxing e-cigarettes and vapor products at high rates, the tax proposal could also undermine public health by preventing smokers from seeking safer alternatives to cigarettes. Research published by the American Medical Association shows that the majority of the toxic chemicals found in smokers that lead to cancer disappear after they completely switch to e-cigarettes, making e-cigarettes a much safer alternative to conventional cigarettes. In fact, research published by The BMJ estimates that there would be 6.6 million fewer premature deaths in the United States if cigarette smokers completely switched to e-cigarettes over the next 10 years. But the proposed bill would tax nicotine vapor products at the same rate, or higher, than cigarettes, which actually may lead to more smoking, as has already happened in Minnesota after a similar tax hike on vaping products.

If Congress actually wants to help West Virginia achieve better public health outcomes, it should look to increase access to safer smoking alternatives like e-cigarettes and heated tobacco products. Vaping products can reduce the harms of smoking and positively benefit public health.

President Biden promised that he would not increase taxes on Americans making less than $400,000 a year, but increasing the federal excise tax on cigarettes will disproportionately increase the tax burden among West Virginia’s economically disadvantaged residents. And by taxing vapes and other products that are safer alternatives to traditional cigarettes, the proposed tax increase would fall short of improving public health outcomes in meaningful ways. 

As Democrats in Congress, including Sen. Joe Manchin from West Virginia, debate the price tag of their proposed reconciliation bill, they should abandon a tobacco tax increase that would disproportionately put the burden of paying for the federal spending on the backs of low- and middle-income individuals in West Virginia and around the country.

The post How a federal tobacco tax increase would impact West Virginia appeared first on Reason Foundation.

The Centers for Disease Control and Prevention reported 70,630 drug overdose deaths for 2019 in the United States, 70.5 percent of which were opioid-related. Amid unprecedented drug-related mortality across the entire United States, Prescription Drug Monitoring Programs (PDMPs) are the most popular interventions states enact to address opioid addiction and overdoses. Prescription Drug Monitoring Programs allow health officials and law enforcement to review the prescribing histories among doctors and patients in hopes of reducing inappropriate prescribing that might lead to addiction or death. However, the inception of PDMPs has been followed by increasing rates of opioid overdose and stable rates of drug addiction. With 19 years of mortality data, this analysis assesses whether Prescription Drug Monitoring Programs have significant effects on either opioid prescribing or mortality.

This study finds that, although Prescription Drug Monitoring Programs’ intermediary purpose to reduce prescribing has been achieved by reducing opioid distribution by 7.7 percent, they have had inconsistent effects on prescription opioid overdoses, while increasing total opioid overdoses by 17.5 percent due to increased mortality from the black market varieties by 19.8 percent.

FIGURE ES1: STATE-LEVEL DEATH RATES FROM LICIT AND ILLICIT OPIOID OVERDOSES FOLLOWING PDMP IMPLEMENTATION BY STATE

Since Prescription Drug Monitoring Programs fail to achieve their ultimate goal of reducing opioid overdoses, their funding should be re-appropriated to more effective mechanisms to reduce addiction and overdose rates, such as providing access to prescription-quality opioids for medication-assisted treatment (MAT).

Introduction and History

Prescription Drug Monitoring Programs (PDMPs) have been used in the United States since the early 20th century. Prior to 1914, natural opiates—the predecessors to modern synthetic or semi-synthetic “opioids”—were unregulated by the federal government and widely available for purchase without prescription in most of the United States.¹ Use among the American public was quite commonplace. According to one article published in The New York Times, one in every 400 United States citizens had some type of opiate addiction by 1911, reportedly due to “the sudden emergence of street heroin abuse as well as iatrogenic [induced by medical treatment] morphine dependence.”²

In response to rising levels of Chinese immigration to the U.S., which was blamed for rising rates of opium use, states like California began outlawing the recreational consumption of various narcotics. San Francisco became the first U.S. municipality to enforce an anti-narcotics law in 1875, outlawing the operation of opium dens, which became state law in 1881. By 1907, California’s State Board of Pharmacy quietly lobbied for an amendment to the state’s poison laws, which prohibited the sale of opium, morphine, and cocaine except by a doctor’s prescription.³

Eventually, the U.S. Congress passed the Harrison Narcotics Tax Act in 1914, the first federal statute regulating the production and sale of opiates and cocaine, which was enforced as a ban on the recreational sale of both products. Under this law, physicians across the U.S. were also restricted from prescribing opiates to addiction patients, and all proprietors of opium products needed to be registered with the federal government, creating the ancestor to the modern PDMP databases.

In an effort to further combat overprescribing, states slowly began to develop their own monitoring programs, the first of which was created in New York in 1918. However, these early PDMPs were rather slow in their collection speeds and used inefficient paper reports to monitor the prescription history of patients. ⁴

These programs developed throughout the mid-20th century and were rather ineffective, as “[p]rescribers were required to report to databases within 30 days, too long a time to reasonably be useful in preventing real-time ‘doctor shopping’ or over-prescribing.”⁵ Additionally, there were no electronic databases tracking which patients had recently filled opioid prescriptions for doctors to reference.

Given the weaknesses of these early PDMPs, few states adopted any type of monitoring program over the course of the first half of the 20th century. However, the proliferation of PDMPs was greatly enabled by the ruling of Whalen v. Roe in 1977, a case that upheld the constitutionality of New York’s precursor of the PDMP under the broad police power given to the states by the Tenth Amendment. The plaintiffs of this case argued that the monitoring program constituted an invasion of patient privacy, due to its collection and storing of prescribing records. Writing for the majority, Justice John Paul Stevens held that, “[n]either the immediate nor the threatened impact of the patient identification requirement on either the reputation or the independence of patients…suffices to constitute an invasion of any right or liberty protected by the Fourteenth Amendment.”⁶ With the constitutionality of patient prescription monitoring upheld, states were able to pursue data collection on prescribing history more thoroughly. Empowered by this ruling, many more states began to operate some form of a PDMP.

By 1990, states such as Oklahoma and Nevada began to adopt electronic reporting systems, greatly expanding the capabilities of these programs. These improvements reduced operations costs and increased the accuracy of the databases, leading other states to consider them as a viable means to monitor opioid prescribing.⁷

In 2003, the PDMP seemed to be an effective way to combat opioid overdose deaths. Given that the majority of opioid deaths in 2003 were due to prescription drugs, the program’s intended purpose of limiting opioid prescribing seemed logical. In that year, Congress further increased funding for state PDMPs through the Harold Rogers Prescription Drug Monitoring Programs Grant, a competitive federal program that allows states to receive funding to “enhance the capacity of regulatory and law enforcement agencies and public health officials to collect and analyze controlled substance prescription data…through a centralized database administered by an authorized state agency.”⁸

Although PDMPs are implemented at the state level, federal law enforcement such as the Drug Enforcement Administration (DEA) has unfettered access to the prescribing records states collect. States such as Oregon and Utah have challenged this power on Fourth Amendment grounds, but federal courts ruled in favor of the DEA saying state law provides a “positive conflict…so that the two cannot consistently stand together” against Oregon in 2014 and “physicians and patients have no reasonable expectation of privacy from the DEA” against Utah in 2017.⁹

Due to increased access to funding and resources under the Harold Rogers Program, by 2016, every state with the exception of Missouri had enacted some form of a PDMP (see Table 1). States vary on the extent to which types of participation in these databases are mandatory and on what types of drugs are monitored. All states with PDMPs monitor at least Schedule II-IV opioids, and the majority of states also monitor prescriptions for Schedule V opioid products, such as codeine cough syrup. PDMPs are administered by state government agencies and compile accessible information on prescribing histories, which is entered into the database by health care providers. These systems are updated on a daily or weekly basis, depending on the state.“¹⁰

The PDMP is now widely regarded as an effective policy mechanism that states can use to combat the opioid crisis. Given the crisis’s wide-reaching effect across the United States, policies such as this aimed at curbing opioid overdoses are now considered a priority by politicians across the political spectrum. Legislators with ideologies as differing as Senators Bernie Sanders (D-VT) and Rob Portman (R-OH) have rallied in unison to support legislation aimed at lowering overdose deaths. In a time of unprecedented political divide and gridlock, it is exceptional for any policy to garner such universal support.

For example, in October of 2018, the U.S. Senate passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act—a bill that strengthened state PDMPs by encouraging interstate sharing of data through nationwide databases such as PMPi Hub and RxCheck Hub and mandated PDMP use for all Medicaid providers—by a margin of 98-1 in the Senate, indicating the unified nature of mainstream political thought surrounding this crisis. Though all PDMPs are administered by the states, this legislation enhanced funding for state PDMPs and created a mechanism by which a patient’s prescription history could be accessed across state lines.¹¹

The dire magnitude of the opioid crisis has created an imperative for legislators, forcing them to act quickly in order to stem the rising level of overdose deaths. As Senator Ted Cruz (R-TX) stated in 2018 while endorsing the SUPPORT for Patients and Communities Act: “[t]oo many lives have been lost to the opioid crisis….I am proud of Congress’s actions today to take a stand in efforts to save millions from the ravages of drug addiction.”¹²

It is this sense of urgency—legislating in response to tens of thousands of overdose deaths every year—that has created almost universal support for these interventions, with little, if any, public debate or criticism of them. The only abstention in the Senate to the SUPPORT Act was Sen. Mike Lee (R-UT), who originally publicly endorsed congressional intervention at the American Enterprise Institute, but later expressed worry that the bill would be ineffective despite its good intentions:¹³

There are some very good elements in this opioid response bill, including strengthening U.S. Customs and Border Protection authority to discover and destroy packages containing illegal controlled substances. Unfortunately, the bill also includes dozens of new grant programs with little accountability for how the dollars will be spent and minimal measurement or analysis on their effectiveness. Good intentions are not enough. In the face of a crisis such as this, we cannot afford to waste precious funds on programs which likely won’t work.¹⁴

This study finds that Prescription Drug Monitoring Programs fail at their major goal to reduce opioid overdoses. Although Prescription Drug Monitoring Programs successfully decrease prescription rates, they also increase the use of black market opioids. Consequently, as Prescription Drug Monitoring Programs cut off users from legal channels of prescribing and force them to switch to more dangerous illicit drugs, this unforeseen substitution to illegally purchased heroin and fentanyl is the principal reason why Prescription Drug Monitoring Programs ultimately lead to more drug overdose deaths.

Full Policy Study— Prescription Drug Monitoring Programs: Effects on Opioid Prescribing and Drug Overdose Mortality

The post Prescription Drug Monitoring Programs: Effects on Opioid Prescribing and Drug Overdose Mortality appeared first on Reason Foundation.

Due to factors including aging patient populations and doctor retirement rates, the U.S. is expected to see a shortage of between 54,100 and 139,000 physicians by 2033, according to a recent report from the American Association of Medical Colleges. Among the states predicted to be hardest hit by the shortfall are Louisiana, Mississippi and New Mexico.

To address the public-health problems the current shortage has caused during the pandemic, some states have temporarily allowed out-of-state doctors to practice within their borders with little to no additional training or certification. State policymakers now have a great opportunity to make the temporary permanent.

Since 1847, the American Medical Association has lobbied every state to enforce their own medical-licensing laws, with peripheral federal oversight, even though licensing qualifications to practice medicine are generally dictated by national specialization organizations such as the American Board of Surgery and are practically identical from state-to-state. Such consistency should make state-level licensure redundant and unnecessary.

However, until recently, doctors were unilaterally barred from practicing in states where they had not been licensed. They couldn’t even provide telemedicine support to patients beyond their state borders. These laws were defended on the grounds that they promote safety, but as with most professional licensing laws, the real motivation was, at least in part, money. Medical boards have used licensing regimes to rake in over $100 million annually in certification and testing fees from aspiring doctors.

When the COVID-19 crisis hit the U.S. health-care system last year, the limitations of state licensing quickly became apparent. Hospitals in regions with high COVID-19 case numbers were in desperate need of more physicians, and the temporary relaxation of cross-state licensing restrictions enabled hard-hit hospitals to staff up quickly to better cope with surges in COVID cases. As a result of this successful experiment born of crisis, even the AMA is now beginning to support the idea of universal licensing within the United States.

One state is pointing the way to more sensible licensing regimes. Utah has not only permanently opened its doors to doctors from other states but also implemented policies to speed up their licensing processes. In fact, Utah has been at the forefront of medical access for years, even allowing doctors licensed in Canada to practice within its borders since 2014.

And the state has continued to build on these sensible policies: Anticipating the COVID-19 hospitalization surge in late March 2020, Gov. Gary Herbert signed legislation to streamline licensing in nearly all non-medical fields. That freed up resources for Utah’s Division of Occupational and Professional Licensing to focus on approving new doctors who wanted to work in the state, and division staff were able to approve 22 percent more doctors in 2020 compared to 2019. It’s likely that these additional doctors are contributing to Utah’s low COVID-19 death rate, currently the nation’s sixth-lowest.

Technically, Utah is willing to license doctors certified in any country, but the state gives preferential treatment to Canadian-certified doctors because that country’s licensing requirements are so similar to those in the United States. Non-Canadian foreign doctors still must complete two years of Utah medical residency before they can practice in the state. Many other states require Canadian doctors to complete this two-year residency as well, but Utah’s policy has allowed a number of Canadian doctors to treat COVID-19 patients in the state immediately.

But why stop at Canada? New Jersey did temporarily allow physicians from other countries to practice in the state at the start of the COVID-19 pandemic. Unfortunately, the state has already suspended new applications, but such provisional licensing for all foreign doctors should be the next step for all states.

The COVID-19 pandemic has shed light on regulations that have prevented the U.S. health-care system from operating as efficiently as possible. States with immediate physician needs amid the pandemic, and those expecting to see doctor shortages in the coming years, should follow Utah’s lead. It’s never been more important to allow doctors to practice where they are most needed.

A version of this column previously appeared in Governing. 

The post How State Policies Are Worsening The U.S. Doctor Shortage appeared first on Reason Foundation.

The release of the original report, by Gaiha et al., coincided with a letter by Rep. Raja Krishnamoorthi (D-IL), who used the study’s results to justify demanding “the FDA to clear the market of all e-cigarettes, temporarily, for the duration of the coronavirus.” Krishnamoorthi’s call received extensive media coverage.

Similarly, Bonnie Halpern-Felsher, one of the study’s co-authors and editor of the Journal of Adolescent Health (JAH), was quoted in stories about the study in The New York Times and other outlets, where she repeated the assertion. The New York Times, for example, wrote:

…a recent survey of more than 4,000 people ages 13 to 24 found that vaping was strongly linked to catching the coronavirus. But Bonnie Halpern-Felsher, a pediatrics researcher at Stanford University and an author on the study, said that there was probably more than biology at play.

But while it was being used by members of Congress and cited in the media, the study also raised eyebrows among researchers familiar with the evidence related to the effects of vaping. A number of experts responded swiftly to the study’s abnormal findings that lacked a credible causal theory.

What raised many questions at first was the fact that the fractions in the study’s descriptive statistics were not possible given the sample sizes, a sure sign of mathematical error. In response, JAH published four letters, all touching on different limitations of the study, that argued the errors rendered the study useless for policy suggestions.

In one of the letters, professors Konstantinos Farsalinos and Ray Niaura criticized the inconsistent results commenting. “It is not biologically plausible that e-cigarette trial or experimentation would cause effects that result in stronger predisposition to COVID-19 than current/regular use,” they wrote.

Their letter then discussed how extrapolating Gaiha et al’s descriptive statistics to the entire population during the study period would mean both young adults and teens represented 1) the majority of people who were tested for COVID-19 and 2) about half of the total positive COVID-19 cases, which are both far lower according to the Centers for Disease Control and Prevention.

Similarly, professors Brad Rodu and Nantaporn Plurphanswat pointed out in their own letter how the study’s descriptive statistics for total positive cases among “ever-users of e-cigarettes only”, “ever-dual-users of both cigarettes and e-cigarettes”, and “past 30-day dual-users” meant that there were only 5, 3, and 5 total positive COVID-19 cases in each group sample, respectively, out of about 2,184 total respondents who reported they ever tried e-cigarettes. Typically, results from such small case counts are not considered useful in the scientific community.

Meanwhile, Dr. Robeto Sussman and I found the most egregious limitation of Gaiha et al. was their failure to control for the percentage of the population in the e-cigarette user and nonuser group samples that were tested for COVID-19 in the first place. According to the study’s descriptive statistics, e-cigarette users were over three times as likely to be tested for COVID-19 as nonusers.

We suspected that this was the main reason e-cigarettes users tested positive for COVID-19 at over three times the rate of nonusers. Our letter published by JAH described a statistical “conditional-probability” identity, proving that the authors would produce biased results if they did not control for testing.

Plainly, you cannot test positive for COVID-19 if you were not tested in the first place.

Although Dr. Halpern-Felsher and six other authors (which did not include either of the other two original study authors), gave detailed justifications for why Gaiha et al. findings are still useful despite criticism from these letters, they did not respond substantively to the letter I wrote with Sussman.

In fact, the response letter gave two examples of studies that controlled for testing, hinting that Dr. Halpern-Felsher concedes that her study’s methods may depart from what is standard in the epidemiological literature. As justification for their methods, the response simply states our suggestion “is akin to ‘sampling on the outcome’ that could produce biased results. We find the suggestions from Rich and Sussman to be interesting future research ideas.”

Dr. Sussman and I specifically requested a reanalysis that controlled for testing, but we are not aware of any such reanalysis having been undertaken.

Technically, if e-cigarettes disproportionately caused COVID-19 symptoms and this led young e-cigarette users to get tested proportionately more often, Gaiha et al. could make a case for not controlling for testing. But since about half of positive COVID-19 tests come from people who are asymptomatic and the vast majority of people who are tested don’t have symptoms, this justification does not work for their study. In fact, after stating that the results could not be used to “imply causality,” the authors postulated that “removing a mask to vape or smoke could potentially increase exposure to the virus.”

We argue that the study’s correlation is more likely due to e-cigarette users being tested for COVID-19 more often than non-users in their specific sample.

The post Experts Question Study Claiming E-Cigarettes Are a COVID-19 Risk Factor appeared first on Reason Foundation.

Drugmaker Purdue Pharma, the company behind the powerful prescription painkiller OxyContin that experts say helped touch off an opioid epidemic, will plead guilty to federal criminal charges as part of a settlement of more than $8 billion, the Justice Department announced Wednesday.

The deal does not release any of the company’s executives or owners — members of the wealthy Sackler family — from criminal liability, and a criminal investigation is ongoing. Family members said they acted “ethically and lawfully,” but some state attorneys general said the agreement fails to hold the Sacklers accountable.

The company will plead guilty to three counts, including conspiracy to defraud the United States and violating federal anti-kickback laws, the officials said, and the agreement will be detailed in a bankruptcy court filing in federal court.

It’s easy to place all the blame on Purdue and other profit-motivated companies for the plight of opioid-afflicted communities, but that sort of surface-level examination by policymakers is part of the reason we have an overdose crisis. The most recent increase in opioid-related deaths has less to do with the number of OxyContin prescriptions and much more to do with drug users resorting to dangerous drugs sold by the black market after the government’s crackdowns on prescription drugs.

One of the main accusations against Purdue is that its marketing campaign underplayed the dangers of its opioid OxyContin and the risks of addiction for susceptible patients.  But according to the U.S. Substance Abuse and Mental Health Services Administration, non-medical use of opioid pain relievers remained stable during the period of increased opioid prescribing between 2002 and 2012. Following coordinated interventions across the country, the misuse of pain relievers did slightly decrease after 2012, but substitution to a black-market alternative, heroin, also increased in tandem.

Despite seeing record rates of opioid-related deaths recently, opioid addiction rates have actually dropped 33 percent since 2015. This trend seems to be consistent with most drugs. Cocaine addiction has dropped 33 percent since 2002, but cocaine-related deaths almost tripled over the same period. In fact, the data show that addiction rates for all substances tend to be unrelated to death rates.

Research shows that the increase in opioid-related deaths can sadly be attributed to the fact that people are using drugs, just as often as they always have, but the drug supply is more dangerous due to significant reductions in prescribing since 2012. The Centers for Disease Control and Prevention have even pointed to the fact that most of the recent opioid deaths have been caused by illegal opioids trafficked from China. As Jacob Sullum pointed out in Reason in October:

The perverse effect of restricting access to prescription opioids should not have been surprising, since the crackdown on pain pills pushed nonmedical users toward black-market substitutes that are far more dangerous because their potency is highly variable and unpredictable.

…Illegally produced drugs now account for the vast majority of opioid-related deaths. In 2018, according to the National Center for Health Statistics, the category of drugs that includes fentanyl and its analogs was involved in more than two-thirds of those deaths, while heroin was detected a third of the time. Prescription opioids like hydrocodone and oxycodone turned up in 27 percent of the cases, and many of those deaths also involved fentanyl or heroin.

Unfortunately, there’s too much scapegoating and money on the line for these facts to get in the way of the government’s crusade. For example, Mike Moore, the former attorney general of Mississippi who previously sued Big Tobacco companies for $246 billion, is now leading an effort in Cleveland, Ohio, to liquidate Purdue. He claims the pharmaceutical company falsely advertised to doctors that “if you prescribe your patients [OxyContin], there’s less than one percent chance they’ll get addicted. That was a lie, a big lie.”

But Moore’s claim is incorrect. When Purdue first introduced OxyContin in 1995, the one percent addiction rate that it advertised was conservative and studies show the chance of addiction is even less. In fact, despite opioid deaths that now number in the tens of thousands each year, there has only been one opioid overdose death for every 8,000 opioid prescriptions distributed since 2006.

Moore also claims “the Food and Drug Administration was asleep at the wheel while all this was happening.” That’s false, too. The FDA has actively addressed the concerns about OxyContin, fining Purdue $600 million in 2007 for misbranding and even encouraging the abuse-deterrent OxyContin reformulation in 2013. Unfortunately, it’s well-established that the government-mandated reformulation actually led to more heroin use and opioid overdoses.

Despite shaky accusations, Moore’s coalition of cases has added other pharmaceutical companies to the defendant list, which helps maximize the settlement amount possibilities. Four other companies have already settled for $260 million in Cleveland alone, and Moore is now pursuing hundreds of billions of dollars from the likes of Johnson & Johnson, CVS, and over 600 other defendants.

Individual states have also pursued their own cases but, unfortunately, their accusations tend to be equally littered with misinformation. In Florida, former Attorney General Pam Bondi filed a case against pharmacies that claimed CVS and Walgreens made “unconscionable efforts to increase the demand and supply of opioids into Florida” that “caused 5,725 deaths in Florida in 2016.” But neither company ever advertised their opioids—and there were actually 2,798 opioid deaths in Florida in 2016. Unfortunately, these types of inaccuracies aren’t limited to Florida, with others also frequently overstating their opioid death rates.

However, the precedent for these opioid-related cases shows massive settlements are possible, regardless of the accuracy of claims. During the one state-level case that went to trial, Oklahoma Attorney General Mike Hunter presented the following accusations:

“There are more prescription drug overdose deaths each year in Oklahoma than overdose deaths from alcohol and illegal drugs combined. Oklahoma leads the nation in non-medical use of opioid painkillers. And, in 2016, Oklahoma ranked number one in the nation in milligrams of opioids distributed … per adult.”

Every claim in Hunter’s statement was wrong but that didn’t stop him from getting a judge to rule Johnson & Johnson had to pay $572 million for Oklahoma’s opioid crisis. In contrast to Hunter’s claims, in 2016 deaths from illegal stimulants like cocaine and methamphetamine alone surpassed deaths from opioid painkiller prescriptions in Oklahoma. Likewise, contrary to his claims, alcohol-induced deaths, though not all technically overdoses by definition, nearly doubled prescription opioid deaths that same year. And Oklahoma was neither the leader in painkiller misuse nor opioid distribution per adult. It’s certainly clear that too many people were dying from opioids in Oklahoma, but Hunter’s blatant inaccuracies should’ve undermined his authority to assess damages.

It is clear that the government’s over-regulation of pharmaceutical products has been followed by more death. In this case, government policies have forced or encouraged pain patients to turn to more dangerous drugs, including heroin and fentanyl. But while it continues to target drugmakers, pharmacies, and others, do not expect the government to be held responsible for its own role in pushing prescription drug users to more dangerous drugs.

The post As Purdue Pharma Takes the Fall, Don’t Forget the Government’s Role In the Opioid Crisis appeared first on Reason Foundation.

Set to take effect in January 2021, the ban would prohibit the sale of all flavored products that contain nicotine, including flavored vaping products and menthol cigarettes. An exception has been made for hookah and premium cigars, but tobacco manufacturers stand to lose millions in revenue as the ban targets their most popular flavored products.

Unfortunately for big tobacco, they don’t have much of a case. As they argue, the Tobacco Control Act does prevent states and local governments from setting their own tobacco product standards, but the same page of this restriction explicitly states any government can still prohibit any class of tobacco product for any age group. A more-or-less identical flavor ban went into effect in Los Angeles County earlier this year and when the tobacco industry attempted to challenge it in court, the case was thrown out.

However, California should note the unintended consequences of an identical tobacco flavor ban have been destructive in Massachusetts, which is on pace to lose over $93 million in tax revenue after becoming the only other state to enforce similar restrictions. Black markets were more than happy to traffic newly illegal flavored tobacco products from neighboring states.

California is inviting an even larger black market to develop. And since menthol cigarettes are disproportionately popular among people of color, the ban puts disadvantaged communities at further risk of the potential violence and overpolicing that can come with illegal activity. Meanwhile the state is preserving the legality of tobacco products mostly used by white people.

Additionally, the motivation for California’s “Stop Tobacco Access to Kids Enforcement” Act, is built on a false premise. From 2019 to 2020, youth use of e-cigarettes has already dropped almost 30 percent and over 50 percent for high and middle school students, respectively. And menthol cigarettes aren’t uniquely addictive or appealing to youth.

The majority young people who smoke prefer regular cigarettes. In fact, states with higher distribution rates of menthol relative to regular cigarettes actually have lower rates of youth smoking.  The most popular e-cigarettes flavors used by young people reflect the tobacco products used by the adults around them, which a state flavor ban will do little to address.

Cigarette use in California, and across the country, has been falling for decades. And the recent acceleration of smoking cessation is disproportionately the consequence of smokers switching to much-safer vaping products, the vast majority of which are flavored. Californians have realized that smoking almost always lowers one’s life expectancy and brings painful diseases at the end of life.

But now that tobacco is unpopular enough to move forward with targeted prohibitions, unfortunately California is again implementing laws that will disproportionately and negatively impact disadvantaged communities.

A version of this column previously appeared in the Orange Country Register. 

The post How California’s Flavored Tobacco Ban Will Hurt Communities and Budgets appeared first on Reason Foundation.

According to the Congressional Budget Office (CBO), the SAFE Banking Act would save the federal government approximately $3 million in direct spending over five years, mostly from its effect on federal deposit insurance. With Congress and President Donald Trump having already issued a massive $3.6 trillion in coronavirus stimulus spending, and over $1 trillion in additional spending in the Senate GOP’s proposed Health, Economic Assistance, Liability Protection and Schools Act (HEALS Act), some have derided the potential marijuana banking act revenues as insignificant in the grand scheme of spending.

In sheer dollars, that’s true. However, the CBO analysis fails to consider potential recuperated tax revenue from better compliance, and other federal agencies suggest the CBO’s projections related to marijuana banking reform may be majorly underestimating its potential.

The Treasury Inspector General for Tax Administration recently released a report estimating that there were $48.5 million in unassessed taxes in the legal and regulated marijuana industry for fiscal year 2016. Incentives for tax compliance are low in an industry that largely has no access to banking services—due to federal law—and detection of noncompliance is difficult. 

Since that estimate reflects 2016 data, it is important to note that four additional states have since permitted recreational marijuana sales while eight additional states have permitted medical sales. This has increased the size of the legal marijuana industry 123% — from $6.7 billion to over $15 billion in 2019. Thus, it would be reasonable to say the federal government could have missed out on more than $100 million in tax revenue in 2019 due to its reluctance to address issues like legal marijuana banking.

And none of these revenue estimates consider the effects on state and local coffers. In the city of Sacramento, for example, regulators found large discrepancies between the receipts marijuana companies report on their financial statements compared to their receipts reported to the city. The Wharton School at the University of Pennsylvania estimates that Sacramento alone amasses $9 million per year in underpaid taxes due to poor recordkeeping and inaccurate financial statements, which amounts to nearly double the revenue collected by the city through fees and taxes on annual reported cannabis sales. 

Issues of underreported marijuana income are endemic across all municipalities and states that have regulated cannabis. This should come as no surprise since cash-based businesses tend to underreport their incomes by 50% in general, which might be even larger in the marijuana industry as suppliers transition from illegal to regulated markets. Additionally, employees of cash-based businesses tend to report less than 20% of their incomes to the Internal Revenue Service (IRS). The best way to address these issues would be to allow marijuana businesses access to banking services, which provide much better records for accounting purposes.

The country is in a recession and experienced an unprecedented 32.9% drop in gross domestic product (GDP) for the second quarter of 2020—due largely to the coronavirus pandemic and the economic lockdowns many state and local governments implemented. While seeking to grapple with the pandemic, recession—and eventually needing to confront the nation’s unsustainable spending, both conservative and liberal policymakers in Congress should consider provisions, like marijuana banking law reforms, that could help the economy, state and local governments, small businesses, and be a net positive to the federal budget.

In states that have legalized cannabis, marijuana companies are attempting to operate legal, regulated businesses despite open hostility from the federal government. Congress should, at minimum, consider legislation that maximizes revenue it collects from the legal cannabis industry while it addresses the discrepancies between federal and state laws.

The post How Congress’ Proposed Marijuana Banking Reform Would Boost Government Budgets appeared first on Reason Foundation.

A recent bill introduced by Sen. Mike Braun, R-Ind., and Rep. Carol Miller, R-W.V. — the Helping Gig Economy Workers Act — seeks simply to give digital employers the freedom to provide masks and other PPE to their workers. The bill would permit a narrow employer-employee exception to allow companies like Uber to provide PPE, such as masks, during the pandemic. The ability for companies to provide PPE to “contractors” would only last until June 30, 2021, or after the COVID-19 public health emergency declared by the secretary of Health and Human Services expires.

You’d hope regulations wouldn’t interfere with any organization distributing masks to anyone for any reason, but don’t underestimate the selfish tactics of American special interests. Major union advocates, such as the National Employment Law Project (NELP), are deriding the bill as an attempt by new gig economy companies to evade labor laws.

NELP is arguing that when companies provide equipment to contractors, like masks, it is evidence of a clear employer-employee relationship that should be subject to federal regulations. Contractors can technically join and start unions, but they are not subject to the same federal protections as regular employees, so union groups are leveraging any argument they can find to reclassify gig-economy workers. This is so their union interests don’t have to compete against gig workers like Uber drivers, who don’t receive minimum wages and health benefits required for most full-time employees.

We shouldn’t be having this employment classification battle over COVID-19. Companies like Uber, Lyft, DoorDash and Airbnb are operating legally as we speak, and any effort to restrict their workers’ access to quality masks and other PPE puts millions of workers and customers at higher risk of infection.

America is enduring a public health emergency. While most research is preliminary, one recent randomized survey by researchers at Indiana University found COVID-19 has a death rate six times greater than the seasonal flu, which killed up to 62,000 people last year. Since COVID-19 also appears to be more contagious than the flu, we need to remove regulations that are preventing companies from protecting their workers.

Providing masks with respirator features is currently the surest way to protect workers while they serve the public. And the country needs to reduce regulations on the production of masks that actually filter the air. The cloth masks recommended by the Centers for Disease Control and Prevention can slightly reduce community infection rates, according to epidemiologist Michael T. Osterholm. After federal laws acknowledge digital gig companies should have the unabridged freedom to provide personal protective equipment to their workers, moving towards all Americans having access to N95-quality masks or better could help reduce the spread, the death toll, and help make more jobs, events and economic activity safe and possible.

In the meantime, Congress shouldn’t let special interests leverage worker safety in a fight against the gig economy. Those working through sharing-economy platforms are currently risking their health to provide essential services to Americans. Unions are free to pursue their dream of reclaiming the market shares of various industries where technology has rendered them obsolete, but they don’t need to risk public health in doing so.

A version of this column first appeared in The Detroit News. 

The post Bill Would Allow Gig Economy Workers to Get Personal Protection Equipment From Companies appeared first on Reason Foundation.

If the general public gains access to appropriate personal protective equipment (PPE), most people wearing masks could resume many activities permitted before the government-mandated lockdowns. Even amid PPE shortages, HHS should immediately follow WHO recommendations to allow demographics at higher risk of COVID-19 mortality access to medical-quality masks and all citizens access to masks/PPE below suggested medical-quality standards. With no precedent of any coronavirus vaccine ever being approved by the FDA, it’s not clear whether a COVID-19 vaccine will become available. However, mass compliance of mask guidance is another way to eliminate the virus. In a perfect world, if every person wore an N-99/N-100 respirator in exposure areas, we could theoretically eliminate new cases and would cut the national case count by more than half within two weeks. Such perfect compliance may not be possible, but the U.S. should use such considerations to determine whether pursuing a vaccine is the most efficient means of ending the COVID-19 pandemic.

While evaluating which PPE to prioritize for health care workers, essential service employees, and the general public, HHS should acknowledge that N95 masks may not provide sufficient protection for individuals with prolonged SARS-CoV-2 exposure. Unfortunately, the current supply of PPE is insufficient to provide all COVID-19 responders with powered, air-purifying respirators and the general public with air-filtering face masks. However, powered devices might not be necessary after evaluating the effectiveness of N99 and N100 masks. If federal agencies take the opportunity to remove manufacturing regulations that are compromising public health, the U.S. may be able to produce the personal protective equipment necessary to contain SARS-CoV-2 and expedite the return to all pre-COVID-19 activities.

Vital PPE: How To Increase Production And Distribution Of Masks Amid Covid-19

This brief is part of a series: Strategies for Combating and Recovering From the Coronavirus Pandemic.

The post Vital PPE: How To Increase Production and Distribution of Masks to Fight COVID-19 appeared first on Reason Foundation.

The study, conducted by researchers at the University of California—San Francisco (UCSF), was developed using data from the National Health Interview Survey (NHIS), which interviews 35,000 households. The UCSF study includes more than 8,000 people ages 18 to 25 and attempts to estimate the medical vulnerability of this population using the CDC’s guidance on possible risk factors for COVID-19.

The study concluded that 32 percent of this population, young adults, is vulnerable to severe COVID-19. But when the smokers and vapers were excluded from the analysis, the study estimated that the percentage dropped to 16 percent. “Recent evidence indicates that smoking is associated with a higher likelihood of COVID-19 disease progression, including increased illness severity, intensive care unit admission, or death,” said the study, which has already grabbed significant attention from major media outlets.

If you assume, without evidence, from the start that smoking or vaping are major risk factors, you should hardly be surprised that removing this group drives down the population’s risk. But the study’s biggest mistake is assuming that smoking or vaping increases the risk of severe COVID-19 in the first place. While these assumptions may be intuitive, they’re not supported by the data as it stands. The CDC itself has provided no evidence to suggest that smoking increases the risk of severe illness from COVID-19, and its own statistics tend to show that smokers are underrepresented in both the number of COVID-19 cases and hospitalizations.

This is the exact opposite of what we would expect if smoking was a significant risk factor. Since COVID-19 tends to attack the respiratory system, officials were worried that smokers could be a higher risk, but the data so far refute this concern. Some scientists have even hypothesized that nicotine may have a protective effect against COVID-19.

A living evidence review spearheaded by academics at University College London (UCL) found that in 12 ‘fair’ quality studies—a broad category where results are considered probably valid— smokers were less likely to test positive for COVID-19 than those who had never smoked. In seven other ‘fair’ quality studies, smokers were no more likely to be hospitalized as a result of COVID-19 than never smokers. The review also showed there was no significant difference in disease severity between smokers and nonsmokers. However, in five ‘fair’ quality studies, smokers were more likely to die in-hospitals of COVID-19 than those who had never smoked. Unfortunately, the UCSF study does not address or cite any of this research.

What’s even more jarring about the UCSF study is that vaping is classified as a smoking-related risk factor. Nowhere does the CDC list vaping as a possible risk factor for severe COVID-19. And there is currently no evidence from anywhere else in the world indicating vapers are at higher risk for COVID-19. Instead, UCSF researchers cite a study published in the British Medical Journal (BMJ) on the respiratory effects of e-cigarettes and an article by the head of the National Institute on Drug Abuse (NIDA).

The BMJ paper is far from instructive when it comes to the risks of e-cigarettes. It systematically ignores evidence contradicting the claim that vaping is safer than smoking and selectively reports negative conclusions without addressing their validity or critiques. Similarly, the NIDA article suggests vaping like smoking “may also harm lung health” but concedes it’s unknown whether vaping can lead to diseases like chronic obstructive pulmonary disease, COPD. The only evidence NIDA cites is a study showing influenza virus-infected mice exposed to e-cigarette vapor for four months.

The cottage industry of anti-vaping research has left some academics red-faced. Stanton Glantz, also of UCSF and an e-cigarette critic, had his study claiming vaping doubles the risk of heart attacks deemed unreliable and retracted last year. A separate study he co-authored earlier this year, claiming e-cigarettes are an independent risk factor for respiratory disease, is the subject of a working paper by economists at Cornell. Their replication of Glantz’s work found “no evidence that current or former e-cigarette use is associated with respiratory disease,” which might lead to another retraction.

Unfortunately, any study portraying tobacco or vaping in a negative light seems more often than not presumed to be true, no matter how weak or methodologically challenged. Conversely, any evidence suggesting the opposite is treated as suspect. In this case, there’s no actual evidence as of yet connecting vaping or smoking to increasing young peoples’ susceptibility to COVID-19.

A version of this column previously appeared on RealClearHealth.com.

The post Smoking, Vaping and the Risks From COVID-19 appeared first on Reason Foundation.

To avoid similar tragedies, many jurisdictions, ranging from cities to entire countries, implemented mandatory lockdowns. Superficially, these seemed to have the desired effect of slowing transmission in the short term. However, while some studies find lockdowns effective in slowing transmission of the virus, several studies suggest that much if not all the reduction in transmission would have occurred anyway due to voluntary measures.

Meanwhile, the lockdowns themselves have had devastating effects on economies, societies and even human health. Something needed to be done, but lockdowns are a blunt instrument, affecting all activities and locations equally even when the risks of different activities, businesses, workplaces, and locations are also quite different. The costs of not looking for more-refined ways to reduce risks from the virus were enormous.

The measures discussed here offer an adaptable range of options, recognizing that no single approach will work best everywhere. Individuals and businesses in rural areas may not need to use as many tools to reduce risk as those in urban areas. Communities with more vulnerable populations, such as retirees, may need to take different measures from college towns. As governments consider policies to prevent a second wave, more data-driven approaches based on test and trace are desirable.

Full Brief — COVID-19 Lockdown Problems and Alternative Strategies to Reopening the Economy

This brief is part of a series: Strategies for Combating and Recovering From the Coronavirus Pandemic.

The post COVID-19 Lockdown Problems and Alternative Strategies to Safely Reopening the Economy appeared first on Reason Foundation.

Although the coronavirus has been characterized as a once-in-a-century pandemic, cigarette smoking will likely still contribute to many more deaths than coronavirus this year and many years to come. The Centers for Disease Control and Prevention (CDC) estimate that cigarette smoking kills nearly 500,000 Americans every year, which is more than twice the White House’s worst-case fatality projection (that it made at the end of March) of 240,000 deaths from coronavirus. 

Gov. Andrew Cuomo has been battling the New York courts to ban flavored e-cigarettes since last year, but misinformation surrounding the current coronavirus pandemic promulgated by certain officials and New York Lt. Gov. Kathy Hochul finally persuaded state legislators to pass the ban. New York is now the fourth state to outlaw flavored vaping products, and other states, like Washington, might soon follow this dangerous precedent.

Studies from JAMA Network Open, The BMJ, Annals of Internal Medicine, and the New England Journal of Medicine all report e-cigarettes are substantially safer to use than combustible cigarettes, and Public Health England concludes e-cigarettes are at least 95 percent safer to consume than combustible cigarettes. The aforementioned study in The BMJ estimates if every adult cigarette smoker switched to vaping in the U.S., approximately 6.6 million fewer Americans would die premature deaths.

With such unanimous research showing the health advantages of vaping over smoking, public health officials in America should be utilizing, not demonizing, flavored e-cigarettes in their efforts to reduce smoking, just as the United Kingdom is doing. In fact, countries hardest hit by the coronavirus, like Italy, Spain, and France, have kept their vape shops open throughout the pandemic, with no restrictions on flavors. After all, foreign health departments recognize vaping’s potential to reduce smoking-related fatalities and how flavors are a significant incentive for many smokers to switch away from cigarettes.

Unfortunately, many medical groups in America are lobbying public officials to ban flavored vaping products. The New York State Academy of Physicians, for instance, has gone as far as supporting a total ban on all tobacco products, despite current Centers for Disease Control and Prevention (CDC) data showing smokers are actually underrepresented among coronavirus patients and hospitalizations. The lack of evidence justifying tobacco prohibitions is staggering, but this sort of unsubstantiated advice isn’t the first.

For example, in February, Surgeon General Jerome Adams told Americans to stop buying masks, arguing they don’t prevent exposure to SARS-CoV-2, the virus causing coronavirus. As it turns out, masks are the most important personal protective equipment the general public can use to help prevent COVID-19 exposure, but the surgeon general argued otherwise when the national case count was still low, in an apparent effort to reserve masks for health care workers.

The public should be wary of so-called expert advice on vaping. This is evident in the surgeon general’s own report on smoking cessation, which alleges “the evidence is inadequate to infer that e-cigarettes, in general, increase smoking cessation.” However, in the same report, Adams cites a New England Journal of Medicine randomized-controlled study showing e-cigarettes are twice as effective as current Food and Drug Administration-approved tobacco cessation products to help smokers quit cigarettes.

Now, federal health officials are joining New York to ignore vaping’s benefits and to suggest e-cigarettes are a risk factor for contracting coronavirus. The director of the National Institutes on Drug Abuse, Nora Volkow, is postulating chronic obstructive pulmonary disease (COPD) might be a risk factor for coronavirus and vaping might be linked to COPD, so vaping might increase risk for contracting coronavirus. This warning doesn’t acknowledge there’s no evidence linking vaping to COPD, but Volkow also seems to have missed the recent research from The Lancet showing COPD-like comorbidities are actually underrepresented among coronavirus patients. Members of Congress are also leveraging such claims to call for a complete prohibition on vaping to combat the virus, which would only escalate the current public health tragedy.

There’s no research supporting the public health justifications being used to ban e-cigarettes amid the coronavirus pandemic, but, unfortunately, that doesn’t seem to matter. A lot of tobacco controllers aren’t interested in public health compromises—many want to ban as many products as possible in order to move closer to total tobacco prohibition, regardless of overall harm. No response to a public health crisis is perfect, but our institutions should not use issue bad guidance and rules that cause more harm than good.

A version of this column previously appeared in The National Interest. 

The post Why Policymakers Are Wrong to Use the Coronavirus Crisis to Push Vaping Bans appeared first on Reason Foundation.

Many countries have reacted to the COVID-19 pandemic by locking down whole economies. While this blunt approach has successfully reduced transmission of the virus, it has also starved economies, making the medicine often as bad or worse than the ailment. A more-tailored risk-based approach, as has been used by countries that have successfully controlled their outbreaks, would curtail transmission by the most likely sources, while allowing for more individual movement by the least likely transmitters, providing for the safest reopening of the economy.

We undertook an extensive review of evidence regarding approaches to (a) limiting the spread of SARS-CoV2, the virus that causes COVID-19; (b) reducing mortality from COVID-19; (c) enabling the maintenance of supply chains and essential services; (d) enabling more widespread opening of the economy once effective measures have been put in place to reduce transmission and contain local outbreaks.

Based on this review, we identified several actions that, if taken together, form a coherent and effective approach. Some of these actions are best undertaken by the private sector. Some require government action—though in most cases that action is at a relatively decentralized level: town, county, city, or other local jurisdiction, rather than state or federal. Overall, they can be construed as a public-private partnership.

A. Measures to identify the scale of the infection, including hotspots, and contain it

The following three steps are intended to discover how widespread COVID-19 is in a jurisdiction, identify emerging virus hotspots or “clusters”, contain those clusters and reduce transmission generally. These steps should be implemented as soon as possible.

1. Undertake population screening for the virus (SARS-CoV2), as well as antibodies to the virus, in order to locate clusters of current and past infection.

2. Simultaneously undertake targeted testing and contact tracing, both manually and through the use of contact tracing apps, in order to identify as far as possible all those who have the virus.

3. Incentivize full isolation for all who test positive for the virus and anyone identified as at risk due to contact with an infected person, until they are able to have a test. Retest individuals for both virus and antibodies after 2 weeks if non- symptomatic at that time.

B. Support the development of risk-based systems that will enable individuals and companies to engage in an increasingly wide range of economic and social activities

The next four steps are intended to enable individuals and companies to understand better the infection risks associated with particular actions and interactions, and to set rules that appropriately limit those risks.

By taking these steps, it should be possible to implement a phased reopening of businesses and other institutions, and relax stay-at-home requirements, while maintaining appropriate mitigation measures.

The objective is to replace a system that punishes the vast majority of people and businesses with one that requires only those who are infected or likely infected to self- isolate. Those least likely to be infected are able return to work and more normal activities in relative safety.

4. Support the development of an infection-risk based Red-Amber-Green (RAG) CV19 status system for individuals, activities and jurisdictions, which can be used to determine who can and cannot do what, where.

5. Support the use of privacy- and-autonomy-protecting authenticated CV19 status app(s) for access to activities. The purpose of these apps is to enable individuals voluntarily to share their status with others, in order to ensure both parties are able to take appropriate measures to limit risk. The apps could also be tied to a contact tracing system, thereby improving the effectiveness of that system.

6. For many activities in many places, it will likely be necessary to use masks and other personal protective equipment (PPE). Given the current lack of adequate PPE supply, it is important that any unnecessary barriers to production and distribution be removed. In particular, current federal regulations must be relaxed.

7. Businesses should be encouraged to develop best practices for limiting exposure to CV19, which might be formalized as “CV19 standards”. Given concerns about liability for negligence resulting from exposure of staff and customers, Congress should consider limiting liability for businesses that adopt these standards.

C. Encourage the development of effective therapies and vaccines

The final steps in the plan relate to the development of therapies and vaccines. It is expected that the former will reduce the severity of COVID-19 and lower the mortality rate. It is hoped that the latter will enable widespread immunity and hence return to normalcy.

8. Incentivize the rapid development of safe and effective treatments and vaccines. New drugs and vaccines usually take months or even years to test in trials involving thousands of people. Since time is of the essence, new, more efficient solutions are needed—and to a considerable degree are being applied. This has required the relaxation of some regulations.

9. Once effective treatments are available at sufficient scale, so that the case fatality rate is substantially reduced, it may be possible to adjust the risk- proportionate restrictions on individuals, activities and jurisdictions. Given that the main justification for the restrictions was the feared high rates of hospitalization and fatality, which threatened to overwhelm healthcare systems, it makes sense that as effective therapies arrive, the curve will automatically be flattened, so the restrictions can be removed.

10. Once an effective and safe vaccine is available and deemed to be “preventative,” it will be made freely available to all. Most restrictions on vaccinated individuals will be removed. Once a sufficient proportion of the population has immunity, either from the vaccine or having COVID-19, the remaining restrictions may be removed.

Actions 1 through 7 can and should be implemented more-or-less simultaneously. This would enable the rapid removal of many restrictions on movement, while simultaneously protecting the most vulnerable and containing the spread of the virus. It is not necessary to test everyone before removing many of these restrictions.

These measures offer an adaptable range of options, and no one approach will work everywhere. Rural areas may not need to use as many tools to reduce risk as urban areas do, and communities with more vulnerable populations, such as more retirees, may need to take different measures from college towns. In all cases, more data-driven approaches based on track and trace are desirable.

For similar reasons, some jurisdictions will be able to open up more rapidly than others, based on the assessment of local risk factors. Other jurisdictions may have to remain subject to more restrictions for a while longer.

Working Paper: An Evidence-Based Approach to Ending the Coronavirus Crisis

The post Working Paper: An Evidence-Based Approach to Fighting the Coronavirus Pandemic appeared first on Reason Foundation.

Last December, Jeffrey Miron and I published our own state-level, cross-sectional analysis in Reason that similarly concluded: “Overall, states with legalized marijuana have reported approximately 6.7 fewer lung injuries per million people than states that have not yet permitted recreational cannabis sales, according to our analysis of CDC data.”

Vaping-Related Illnesses Per Million People
(Click a state for more information)

Covid test

Similar to the JAMA authors, we chose to compare states that permitted recreational marijuana sales to all other states, even if they regulated a medical marijuana market without a recreational market. We did this because we hypothesized that vaping-related injuries were almost always caused by products purchased in illicit markets and that only permitting a medical marijuana market would not provide sufficient access for most recreational marijuana users to obtain safe products. The JAMA authors’ analysis agrees with our sentiment, commenting, “The difference in the EVALI case rate between medical and prohibition states was not statistically significant.” And with our estimate right between both of the authors’ estimates, it looks like our results match perfectly.

Based on these results, it can be said that marijuana prohibition was a major factor in causing the vaping-related lung-injury “epidemic.” According to both analyses, if every state permitted a recreational marijuana market, there would have been approximately 1,663 fewer vaping-related lung injuries — a 62 percent decrease from approximately 2,667 total recorded injuries in 2019.

While considering these estimates, it’s important to remember that marijuana is still technically illegal in every state due to federal law. As of now, 11 states and Washington, D.C. have voted to “legalize” marijuana, but since the federal government’s Schedule I (total prohibition) designation supersedes all state laws, current “legalization” should just be interpreted as supplier decriminalization. This means that if the federal government legalized marijuana, we would expect even fewer vaping-related lung injuries than the studies estimate.

After months of suggesting legal vaping products could be to blame for vaping illnesses in 2019, the Centers for Disease Control and Prevention (CDC) did not concede that the lung injuries were disproportionately caused by “tetrahydrocannabinol (THC)-containing products primarily from informal sources” until January 2020. In contrast, organizations that looked closely at the data, like the Competitive Enterprise Institute, Reason Foundation, and the Cato Institute, pointed out that the illicit market was the culprit as early as July 2019.

With federal bureaucracies like the CDC and Food and Drug Administration (FDA) slow to make this distinction, the public was confused as the agencies waged a war against legal nicotine e-cigarettes, which have not been shown to be the cause of a single recorded vaping-related lung injury. And during the current coronavirus pandemic, it’s important for agencies at all levels to allow marijuana businesses and tobacco shops to operate so that illicit manufacturers don’t replace the regulated suppliers.

As Reason’s Jacob Sullum points out, as the ongoing COVID-19 pandemic is devastating hospitals and economies across the globe, it’s high time for public health agencies to prioritize their original purpose — preventing actual epidemics — as opposed to metaphorical “epidemics” of self-endangering behavior. Especially when the government’s prohibition is a significant cause of the problem in the first place.

The post How Marijuana Prohibition Contributed to the Vaping Lung-Injury “Epidemic” appeared first on Reason Foundation.

Grassley is hoping to legislate lower prices for Medicare patients seeking future coronavirus medications. Earlier, Grassley denied accusations of socialism, claiming that the Cato Institute praised the bill’s savings for taxpayers. “Does anyone really think that a libertarian organization would endorse price controls?” he asked.

Of course it would. A libertarian organization should support price controls for government programs, as it would be quite un-libertarian to allow private companies to extract as much money as they can from taxpayers. But the bill goes much further than merely taming government spending.

It introduces broad authority to the secretary of Health and Human Services to set market pharmaceutical prices by defining price increases and debuts that require public “justification” based on arbitrary criteria. If the health secretary were to find the companies’ explanations inadequate, he or she could fine them daily until they lowered their prices.

Republicans constantly decry interventions resembling socialism, pointing to doctor shortages that leave Canada and the United Kingdom with lower cancer survival rates than the U.S., but increasing government control is also nothing new for Republicans like Sen. Grassley, who will apply for Trump’s second federal bailout to pay $12 billion to the Iowa farmers he represents — and his own farm. Grassley’s family has actually collected over $1.6 million from the federal government from 1995-2017. And during the George W. Bush Administration, Grassley even lobbied for an ethanol requirement in gasoline for what Republicans uncharacteristically justified as environmentalism. But the production of ethanol actually adds to the total carbon footprint of automobiles, so it was really just a way to raise the price of corn and payout rich, politically-connected farmers like Grassley.

Republican socialism isn’t the way to reduce drug prices. It’s the government’s fault that drug prices are so high in the first place. The only sustainable solution is to liberalize health care from government control.

Consider a Vice News report that found that Novolog insulin pens were $17 in Mexico, but $540 in America. Why can’t Americans just buy the exact same FDA-approved drugs from foreign pharmacies online? Probably because it’s illegal. After all, pharma heavily lobbied for foreign import bans — bans that are popular in socialist regimes.

Some conservatives deride drug reimportation as “importing socialism,” arguing that permitting Americans access to the price controls negotiated by other countries would destroy profit-motivated pharmaceutical innovation. But even if it’s coming from socialist countries, competition is the best free-market solution to compel pharma to improve development and reduce its American prices. It’s odd that Democrats have actually come to support these free-trade principles while some voices at free-market groups like Cato and the Taxpayers Protection Alliance have endorsed the trade restrictions.

Even so, drug reimportation wouldn’t be the sole solution to high drug prices, for which Medicare and Medicaid are largely to blame. As it stands, these federal programs incentivize pharma to keep prescription drug prices artificially high for everyone, because Medicare and Medicaid will only buy prescriptions based on the average and lowest private prices, respectively.

Sen. Grassley’s bill also entrenches pharma’s terrible reimbursement schemes. Yes, the bill should bring some savings to taxpayers. It’ll force pharmaceutical companies to report discounts they give consumers, which they don’t as a way to keep their reported prices high. But reimbursements would still be tied to private market prescriptions, and basic economics tells us that pharma will just increase prices for everyone with private insurance to preserve high reimbursement rates. If we agree that the government should provide health care to the elderly and the poor, the only way to reduce drug prices without impeding innovation is to copy countries like Switzerland, replacing Medicare and Medicaid with individual subsidies to purchase private insurance.

It’s a shame that Republicans only oppose socialism until they’re in power. With the COVID-19 bailouts, Sen. Bernie Sanders is largely correct that Congress supports socialism for corporations and the rich. Corruption has plagued both of America’s major political parties for decades, and unprecedented health care spending will persist until policymakers liberalize the pharmaceutical market from government control.

A version of this column first appeared in the Daily Caller.

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