Doobies over Butts: More Americans Now Smoke Marijuana Than Cigarettes

Gallup has polled Americans for many decades about their smoking habits. About 40-45% of adults smoked cigarettes from about 1945-1975, but the percentage has dropped steadily since then. A 2022 poll showed a new low of 11% being smokers. Roughly three in 10 nonsmokers say they used to smoke.

On the other hand, marijuana usage has climbed steadily since Gallup first asked about it in 1969. Some 16% of Americans say they currently smoke marijuana, while a total of 48% say they have tried it at some point in their lifetime:

Younger adults (18-34) are much more likely to be current users, but the 55+ crowd tried it nearly as much (44%) as the younger cohorts:

Among all adults, opinion is about evenly split on whether marijuana has a positive or negative effect on society and on people who use it. However, opinion is skewed very positive among those who have actually tried it, and negative among those who have not:

(I can’t resist inserting a consistent anecdotal observation by reliable people I know or know of, that habitual smoking of MJ tends to be highly correlated with passivity / lack of initiative, especially among young men. When one young man I know of told his counselor, “Nothing happens [when I smoke weed]”, the response was, “That’s the problem, nothing happens [because with weed you just chill and don’t do the stuff you need to do].” Of course, correlation says nothing about the direction of causation here).

The big gorilla of substance usage is still alcohol. About 45% of Americans have had an alcoholic drink within the past week, while another 23% say they use it occasionally. Alcohol use has remained relatively constant over the years. The average percentage of Americans who have said they are drinkers since 1939 is 63%, which is close to Gallup’s most recent reading of 67%.

A Theory of Certificate of Need Laws and Health Care Spending

I just published a paper on CON laws and spending in Contemporary Economic Policy. As frequent readers of this blog will know, CON laws in 34 states require healthcare providers in 34 US states to get permission from a state board before opening or expanding, and one goal of the laws is to reduce health care spending. The contribution we aim for in this paper is to lay out a theoretical framework for how these laws affect spending.

There have been many empirical papers on this, typically finding that CON laws increase spending, but the only theory explaining why has been simple supply and demand. Health care markets are hard to model for a few reasons, but one big one is that most spending is done through insurers, so the price consumers pay is typically quite a bit lower than the price producers receive. This leads to “moral hazard”- i.e. overuse and overspending by consumers. Normally economists hate monopolies because they lead to underproduction, so in a market with overuse its fair to ask (as Hotelling did about nonrenewable resources)- could two market failures (moral hazard overuse and monopoly underuse) cancel each other out?

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On the Spreading of Monkeypox

New York City has become the second major U.S. city after San  Francisco to declare a state of emergency due to the rise of monkeypox cases: “New York City is currently the epicenter of the outbreak, and we estimate that approximately 150,000 New Yorkers may currently be at risk for monkeypox exposure.”

With the country and the world still feeling the economic/social/personal effects of one pandemic, is there another one on the way? I don’t know, having no special training in epidemiology, but have tried to peruse some reliable sources to find out what I could, and share this information for your examination. I will paste in a general page from a UC Davis article, then conclude with a CDC snip on transmission details.

It seems that monkeypox typically takes pretty close physical contact (especially with skin, body fluids, or e.g. towels/clothing)  to spread, with having multiple romantic partners being a high risk factor. This is the opposite of COVID transmission, where just being in the same room puts you at high risk. However, as with COVID, someone can be contagious in the early stages before they show obvious symptoms. Based on all this, my guess is that monkeypox will not spread in the general population very much, but it will spread significantly in some groups and locales. But that is just my guess.

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From UC Davis “Monkeypox: What you need to know about this rare virus:

What are the signs and symptoms of monkeypox? At what point is it infectious?

Monkeypox starts with fever, then general body aches, malaise, and muscle aches. with the first symptoms are similar to influenza. Those usually precede the development of a rash. You have probably seen photos of the rash. It’s really hard to miss. It starts as macules, which are flat lesions. Then it forms a firm nodule. From there, it becomes a blister, then a pustule (a blister containing pus) and then it scabs over.

According to the Centers for Disease Control and Prevention (CDC), the incubation period (The time from infection to symptoms) for monkeypox is usually 7 to 14 days, but it can range from 5 to 21 days.

People may be contagious at the early signs of fever and stay infectious through the rash until the skin scabs and heals over.

How is it transmitted?

Monkeypox is transmitted through close person-to-person contact with lesions, body fluids and respiratory droplets, and through contaminated materials such as clothing or bedding.  [[ see more on transmission below]]

Can you die from monkeypox? 

Most people with monkeypox will recover on their own. But 5% of people with monkeypox die. It appears that the current strain causes less severe disease. The mortality rate is about 1% with the current strain….

What are the treatments for monkeypox? Is there a vaccine for monkeypox?

The smallpox vaccine has some cross protection against monkeypox. The vaccine is being made available through public health for people who have had contact with confirmed or suspected cases of monkeypox. If the vaccine is given within four days of exposure, it protects about 85% of the time. Even if the vaccine is given up to two weeks after exposure, it may modify the disease, making it less severe. 

In addition, there are some antivirals and immunoglobulins that are available to treat monkeypox.

Is there a way to test for monkeypox?

If a health care provider suspects that a patient has been exposed to monkeypox, they can get a sample of a lesion and send it to the state for testing. If it turns out positive, the result will be confirmed at the CDC.

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From CDC “How It Spreads”:

Monkeypox spreads in a few ways.

  • Monkeypox can spread to anyone through close, personal, often skin-to-skin contact, including:
    • Direct contact with monkeypox rash, scabs, or body fluids from a person with monkeypox.
    • Touching objects, fabrics (clothing, bedding, or towels), and surfaces that have been used by someone with monkeypox.
    • Contact with respiratory secretions.
  • This direct contact can happen during intimate contact, including:
    • Oral, anal, and vaginal sex or touching the genitals  or anus of a person with monkeypox.
    • Hugging, massage, and kissing.
    • Prolonged face-to-face contact.
    • Touching fabrics and objects during sex that were used by a person with monkeypox and that have not been disinfected, such as bedding, towels, fetish gear, and sex toys.
  • A pregnant person can spread the virus to their fetus through the placenta.

A person with monkeypox can spread it to others from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

Trial Updates: Novavax Approved, Potatoes Work

I’m usually the one writing the papers, but I recently did two studies as a participant / guinea pig. Both just released major positive updates.

I joined the Novavax trial in late 2020 to have the chance to get a Covid vaccine sooner; at the time Pfizer had just got emergency approval but wasn’t available to the general public. The smart bio people on Twitter also seemed to think it was likely to be safer, and perhaps more effective, than other Covid vaccines (it delivers relevant proteins directly, rather than using mRNA or a viral vector). The trial results were published over a year ago now, and were in fact excellent:

Results from a Phase 3 clinical trial enrolling 29,960 adult volunteers in the United States and Mexico show that the investigational vaccine known as NVX-CoV2373 demonstrated 90.4% efficacy in preventing symptomatic COVID-19 disease. The candidate showed 100% protection against moderate and severe disease

As usual the FDA dragged its feet, even as other agencies around the world like the European Medical Agency and the World Health Organization approved the US-made Novavax. But last week it finally gave emergency authorization, and yesterday the CDC recommended Novavax. Of course, by now almost everyone who wants a Covid vaccine has one, and this approval is only for adults. But this will be a great option for boosters, as well as for anyone who was genuinely just concerned with the new technologies in the other vaccines (rather than just afraid of needles, or preferring to cut off their nose to spite authority’s face). As the CDC put it:

Protein subunit vaccines package harmless proteins of the COVID-19 virus alongside another ingredient called an adjuvant that helps the immune system respond to the virus in the future. Vaccines using protein subunits have been used for more than 30 years in the United States, beginning with the first licensed hepatitis B vaccine. Other protein subunit vaccines used in the United States today include those to protect against influenza and whooping cough….

Today, we have expanded the options available to adults in the U.S. by recommending another safe and effective COVID-19 vaccine. If you have been waiting for a COVID-19 vaccine built on a different technology than those previously available, now is the time to join the millions of Americans who have been vaccinated

I’m glad I was in this trial- I got a Covid vaccine several months before I otherwise could have, I made a few hundred dollars, and I learned a lot. But it would have been much better if they found a way to do fewer blood draws, and if FDA approval had come quicker. I’ve been in a weird gray area with respect to vaccine mandates for the last year; almost everyone ended up accepting my vaccine card, but I never knew if they were going to say “no, you need an FDA approved one”. I ended up getting Pfizer for a booster even though I think it’s a worse vaccine, partly for this reason, and partly because Novavax said they’d only give me the booster if I did another blood draw and I was tired of that.

The all-potato diet trial I wrote about here also released its results this week. This trial was much less formal, much smaller, and had no control group, so the results aren’t a slam-dunk the way Novavax is. But I think they’re still impressive. I lost 8 pounds in the 4-week trial, but it turns out the average participant who did all 4 weeks did even better:

Of the participants who made it four weeks, one lost 0 lbs…. Everyone else lost more than that. The mean amount lost was 10.6 lbs, and the median was 10.0 lbs.

Their summary also explains other costs and benefits of the diet, showing lots of data as well as many quotes from participants, including two from me. They conclude with some fascinating speculation about potential mechanisms from the boring (literally, lower variety makes eating boring so you eat less) to the speculative (low lithium? high potassium? weird lithium-potassium interactions), check it out if you’re interested in why obesity rates keep rising or if you’re considering doing the potato diet.

I’m glad I was in these two trials- what to try next?

GDP Growth and Excess Mortality in the G7

Two weeks ago my post looked at GDP growth during the pandemic. But of course, economic growth isn’t the only important outcome to look at in the pandemic. Health outcomes are important too, and indeed I have posted about those in the past alongside GDP data.

Today, my chart looks at the G7 countries (representing roughly half of global wealth and GDP), showing both their economic performance (as measured by real GDP growth) and health performance (as measured by excess mortality through February 2022).

The US has clearly had the best economic performance. But the US also had the highest level of excess deaths per capita (not all of this is from COVID — US drug overdoses are also way up — but even using official COVID deaths, the US still tops this group).

Japan had the best health performance, in fact amazingly no cumulative excess deaths through February 2022 (this has risen very slightly since then, but I stopped in February so all countries had complete data). However, Japan also had slightly negative economic growth.

Which country ends up looking the best? Canada! Very low levels of excess deaths, and at least some positive economic growth. Not as much growth as the US, but Canada is the second best performer in the G7.

To give some context of just how low the level of deaths have been in Canada, first recognize that the US had 1.1 million excess deaths in the pandemic through February 2022. If instead our excess deaths had been roughly equal to Canada on a per capita basis, we would have only had 180,000 excess deaths in the US, saving over 900,000 lives.

Some of Canada’s COVID policy have been overly restrictive, such as the vaccine mandates that sparked protests in February 2022. But by then, Canada had already largely achieved it’s COVID victory over the US and most other G7 nations. Compare excess mortality in Canada with the US: the only big wave in Canada that came close to the US was the Spring 2020 wave. After that, Canada was always much lower.

Job Lock is Still Here

Most Americans are covered by employer-sponsored health insurance, either through their own job or a family member’s. This can make it difficult to switch jobs- the new job might not offer insurance, or might have a worse insurance plan or network- locking people into their current job.

Economists have documented since at least the 1980’s how our insurance system seems to reduce job mobility. Several reforms have tried to improve the situation- COBRA, HIPAA, and most recently the Affordable Care Act.

In a paper published this week, Gregory Colman, Dhaval Dave and I evaluate how the extent of “job lock” has changed over time. In short, we find that job lock remains substantial and the Affordable Care Act doesn’t appear to have done anything to improve the situation. The paper has many tables of regression results, but the pictures tell the basic story:

Trends in job mobility for those with and without employer-sponsored insurance (ESI) using Current Population Survey data

The details differ a bit depending on which dataset and identification strategy we use, but a few things are clear:

  1. Macroeconomic factors are dominant in the short run; mobility falls during recessions like 2001 and 2007, then recovers.
  2. The long run trend has been toward lower job mobility for those with AND without employer-based insurance
  3. Those without employer-based insurance are still much more likely to switch jobs (we find 25-45% more likely)
  4. To the extent that this gap has closed since the year 2000, it has come through falling job mobility for those without employer-based insurance more than rising job mobility for those with employer-based insurance

Why does the Affordable Care Act appear not to have improved things? This remains unanswered, but we conclude the paper with some hypotheses:

In fact, our point estimates suggest that job lock actually got stronger following the ACA. One possible explanation for our finding is that the ACA’s individual mandate made insurance even more desirable by fining the uninsured. Another possibility is that workers continue to value employer-provided health insurance more over time as premiums continue to rise

Irish Superman: 4 Weeks of Potatoes

Back in May I mentioned that a study was recruiting participants to try a 4-week all-potato diet. What I didn’t say was that I was joining the study, and I finished this week.

I’m glad I did it; I lost 8 pounds and 2 inches of waistline, going from slightly overweight (BMI 26) to just barely not-overweight (BMI 24.9). Here are some of my notes:

Day 5: Energy boost kicked in today. Feel half my age

Day 6: Potato energy going strong. Feel like Irish Superman

Day 15: Almost too much energy, hard to sit down at a computer and work, took a break to play basketball

So like many people who previously tried this, I can add more anecdotal evidence of weight loss (despite eating all the potatoes you want) and energy. I’ll also echo people who said that “hunger feels different” and not as demanding, and that it “resets your tastebuds” so that previously bland foods taste good (I just had a turnip with zero seasoning and it was almost too intense). Now to answer your likely questions:

Q: Did you actually eat nothing but potatoes for 4 weeks?

A: No, but I got reasonably close. I cooked potatoes in avocado oil and added seasonings, I drank coffee and beer, I ate other vegetables, I had some snacks. Overall I estimate I got 75-80% of my calories from potatoes.

Q: Was it hard to stick to? didn’t you get bored?

A: Being hungry or even bored weren’t really issues, all 5 times I slipped up and ate a meal that wasn’t potatoes I’d say it was for social reasons (I was at a party with great food, at a restaurant with someone, et c)

Q: What kinds of meals did you cook?

A: Lots of home fries and roast potatoes using lots of varieties of potato (russet, gold, red, purple, sweet). Mashed potatoes a few times. McCain’s craft beer fries for my birthday.

Q: Aren’t potatoes bad for you? Why didn’t this make you fat?

A: Anything can be bad for you if you deep-fry it, or otherwise smother it with fats or process it to death. This is probably how most potatoes get consumed in America, but they start as nutritious root vegetables.

Q: What about protein? Doesn’t this kill your gains?

A: This was my biggest concern going into the study. Potatoes do have more protein than I thought, enough to live on but probably not enough to make you strong. My lifts did come down a bit, though it’s unclear if that was due to the lack of protein or just the lower calories and weight loss taking some muscle along with the fat. I was eating high-protein yogurt many days to try to mitigate this.

Q: If this is so great, are you going to keep doing it?

A: No, it was great for the first 14-16 days then just ok. Most of the weight loss and energy boost happened in the first half. If I ever do this again I’m going to plan on two weeks, which I think is also what Penn Jillette suggests. I do think I’ll do potatoes for lunch a lot more often than I used to, and pivot this to a “whole foods / not-ultra-processed” diet.

Q: Is there something special about potatoes? Would any single-food diet work as well?

I’m not sure. Some of the benefit likely comes from cutting out variety, so not eating a lot just because “I need to try everything”. Some likely comes from cutting out specific categories of food, like high fat / high sugar / hyper-palatable. I don’t think that just any food would work, probably most whole foods would, but potatoes are cheap and nutritious. The potato diet leading to weight loss is consistent with many, though not all theories of obesity.

Q: Can I still sign up for the study?

A: No:

Signups are now closed, but we plan to do more potato diet studies in the future. If you’re interested in participating in a future potato diet study, you can give us your email at this link and we’ll let you know when we run the next study.

But you can always just do it yourself.

Cost Plus Drugs

A new online pharmacy funded by Mark Cuban promises to sell prescription drugs at a fixed markup, 15% over cost plus a $3 flat fee. What’s the catch?

As far as I can tell, there are two- they only sell generics, and they don’t take insurance. But I think this will still save many people a lot of money.

The most expensive drugs get that way because they are sold by monopolies, almost always because they were invented less than 20 years ago and are still on-patent. But it’s still possible for older drugs to be sold at huge markups, as Martin Shkreli could tell you now that he’s out of prison (Shkreli’s case is supposedly what inspired Dr. Alex Oshmyansky to start this pharmacy). Sometimes you can still blame these markups on monopolies, just induced by the FDA instead of patents. But even for generic drugs with competitive manufacturing, you still sometimes see large and variable markups at the pharmacy level. So I think there’s still huge value in a pharmacy offering a low and stable markup on generics.

What about not taking insurance? First of all, lower cash prices obviously still benefit the 28 million Americans who don’t have health insurance. But even for those with insurance, it’s surprisingly common throughout health care to find cash prices lower than their copay. I have relatively good insurance but when I checked Cost Plus Drugs for the last two prescriptions my family got, I found that one was 80% cheaper than our copay (the other was about the same as our copay, so we’d only come out even, though we’d presumably save our insurer a lot).

Cost Plus Drugs originally wanted to also work through insurance as a Pharmacy Benefit Manager, but seems to have pivoted to being an “unPBM” that just offers generics to employers to supplement their existing plans. They also want to manufacture some of their own drugs, which seems on track to happen. They were started as a Public Benefit Corporation, so while they are for-profit this lends credibility to the idea that they really do want to keep prices down, not just start with low prices to make a name for themselves. Anyway, this seems like a worthy experiment and I encourage anyone with an expensive prescription to see if you can get it cheaper here.

Sick of high drug prices? Try some low-price anti-nausea mediation

Why Many Substance Use Treatment Facilities Don’t Take Insurance

According to the latest data, about one in four facilities doesn’t accept private insurance or Medicaid, and more than half don’t accept Medicare. This makes substance use treatment something of an outlier, since 91% of all US health spending is paid for through insurance. Still, there are many reasons to prefer being paid in cash: insurance might reimburse at low rates, impose administrative hassles, and generally try to tell you how to run things.

Providers generally put up with the hassles of insurance because they see the alternative as not getting paid. But if demand for their services gets high enough that they can stay busy with patients paying cash, they will often try going cash-only. Some try to generate high demand by providing excellent service. Sometimes high demand comes from a growing health crisis, as with opioids.

Demand can also be high relative to supply because supply is restricted. US health care is full of supply restrictions, but in this case I wondered if Certificate of Need laws were playing a role. As we’ve written about previously, CON laws require health care providers in 34 states to get the permission of a government board to certify their “economic necessity” before they can open or expand. But there’s a lot of variation from state to state in what types of services are covered by this requirement; acute hospital beds and long-term care beds are most common. 23 states require substance use treatment facilities to obtain a CON before opening or expanding.

States with Substance Use–Treatment CON Laws in 2020. Created using data from Mitchell, Philpot, and McBirney

How do these laws affect substance use treatment? We didn’t really know- only one academic article had studied substance use CON, finding it led to fewer facilities in CON states. But I’ve studied other types of CON, so I joined forces with Cornell substance use researcher Thanh Lu and my student Patrick Vogt to investigate. The resulting article, “Certificate-of-need laws and substance use treatment“, was just published at Substance Abuse Treatment, Prevention, and Policy. Here’s the quick summary:

We find that CON laws have no statistically significant effect on the number of facilities, beds, or clients and no significant effect on the acceptance of Medicare. However, they reduce the acceptance of private insurance by a statistically significant 6.0%.

Overall I was surprised that CON didn’t significantly affect most of the outcomes we looked at, and appears to be far from the main reason that treatment facilities don’t take insurance. Still, repealing substance use CON would be a simple way to improve access to substance use treatment, particularly since CON doesn’t appear to bring much in the way of offsetting benefits.

Going forward I aim to investigate how these laws affect health outcomes like overdose rates, and to dig more into the text of state laws and regulations to determine exactly what is covered by substance use CON in different states. As the article explains, we identified several errors in the official data sources we were using. This makes me worry there are more errors we didn’t catch, and there are certainly things the sources just don’t specify, like in which states the laws apply to outpatient facilities. So I hope we (or someone else) will have even better work to share in the future, but for now this article is as good as it gets, and we share our data here.

COVID Deaths, Excess Deaths, and the Non-Elderly (Revisited)

While we know that COVID primarily affects the elderly, the mortality and other effects on the non-elderly aren’t trivial. I have explored this in several past posts, such as this November 2021 post on Americans in their 30s and 40s. But now we have more complete (though not fully complete) mortality data for 2021, so it’s worth revisiting the question of COVID and the non-elderly again.

For this post, I will primarily focus on the 12-month period from November 2020 through October 2021. While data is available past October 2021 on mortality for most causes, data classified by “intent” (suicides, homicides, traffic accidents, and importantly drug overdoses) is only fully current in the CDC WONDER data through October 2021. This timeframe also conveniently encompasses both the Winter 2020/21 wave and the Delta wave of COVID (though not yet the Omicron wave, which was quite deadly).

First, let’s look at excess mortality using standard age groups. For this calculation, I use the period November 2018 through October 2019 as the baseline. The chart shows the increase in all-cause deaths in percentage terms. It is also adjusted for population growth, though for most age groups this was +/- 1% (the 65+ group was 3% larger than 2 years prior).

A few things jump out here. First notice the massive increase in mortality for the 35-44 age group (much more on this later). Almost 50% more deaths! To put that in raw numbers, deaths increased from about 82,000 to 122,000 for the 35-44 age group, and population growth was only about 1%. And while that is the largest increase, there were huge increases for every age group that includes adults.

Also notice that the 65+ age group certainly saw an increase, but it is the smallest increase among adults! Of course, in raw numbers the 65+ age group had the most excess deaths: about 450,000 of the 680,000 excess deaths during this time period. But since the elderly die at such high rates in every year, the increase was as large in percentage terms.

One related fact that doesn’t show up in the chart: while there were about 680,000 excess deaths during this time frame in the US in total, there were only about 480,000 deaths where COVID-19 was listed as the underlying cause of death. That means we have about 200,000 additional deaths in this 12-month time period to account for, or a 24% increase (population growth overall was only 0.4%).

That’s a lot of other, non-COVID deaths! What were those deaths? Let’s dig into the data.

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