Impact of State Policies on Smoking among Individuals with Substance Use Disorder

项目总结/摘要 越来越多的证据支持需要认识到吸烟者与物质使用障碍（SUD）的关键， 在评估与烟草有关的使用和疾病方面，我们需要建立一个差异组，并确定解决这一差异的战略。 吸烟经常与其他非法药物和酒精的使用同时发生，并协同危害健康。许多 随着年龄的增长，从SUD中恢复过来的人仍然依赖烟草，患癌症和其他疾病的风险更高。 吸烟相关的并发症和死亡率（吸烟者SUD的死亡率是非吸烟者的4倍， 吸烟者（SUD）。尽管吸烟者对尼古丁的依赖性更大，戒烟更困难， SUD，SUD吸烟者经常报告强烈的戒烟愿望，烟草依赖治疗（TDT）是 在这个人群中有效。此外，戒烟已多次被证明可以改善SUD 治疗结果，反对在SUD中将尼古丁依赖视为较低优先级的常见解雇 治疗然而，这一人群的TDT率仍然很低。最近，许多州扩大了 医疗补助覆盖TDT，但目前还不清楚这是否增加了治疗服务的使用， 弱势群体。烟草税和其他烟草控制政策也成功地减少了吸烟 率，但对吸烟者SUD的有效性尚不清楚。 我们建议评估扩大TDT覆盖范围和烟草消费税对TDT使用的影响 使用2004- 2016年Medicaid分析摘录的SUD吸烟者的服务、吸烟强度和戒烟率 (MAX)来自所有50个州的索赔数据，以及2004-2018年全国药物使用和健康调查（NSDUH）， 合并到州医疗补助福利和州，市，县一级烟草政策的数据集。以 随着时间的推移，状态内和状态之间的变化的优势，我们采用严格的方法（差异， 差异分析和个人固定效应模型），以评估戒烟政策的因果效应。 在目标1中，我们测试了医疗补助TDT覆盖范围对TDT启动和维持以及戒烟的影响 吸烟的医疗补助受益人与SUD。在目标2中，我们测试了增加香烟消费的效果 在更广泛的全国SUD患者样本中，对吸烟和戒烟的强度征税。 在目标3中，我们评估了TDT和税收政策对医疗补助中烟草使用的综合影响。 受益人为SUD。 我们假设，TDT的保险覆盖激励了TDT治疗寻求，增加税收创造了 强有力的戒烟激励措施，这两项政策将共同提高戒烟率。我们一直与 利益攸关方提出分析，为复杂的现实政策环境中的决策者提供信息， 难以接触到的人群，我们纳入了一个传播计划，为可操作的 通过针对州烟草控制管理人员、州SUD服务机构、SUD治疗 提供者不愿意纳入TDT，和综合行为健康提供者。

Project Summary/ Abstract Growing evidence supports the need to both recognize smokers with substance use disorder (SUD) as a key disparity group in evaluating tobacco-related use and disease, and identify strategies to address this disparity. Smoking frequently co-occurs with other illicit drug and alcohol use and synergistically worsens health. Many who recover from SUD as they age remain dependent on tobacco and are at higher risk for cancer and other smoking-related complications, and mortality (smokers with SUD have mortality rates 4 times higher than non- smokers with SUD). Despite greater nicotine dependence and more difficulty quitting among smokers with SUD, smokers with SUD often report a strong desire to quit, and tobacco dependence treatment (TDT) is effective in this population. Moreover, smoking cessation has repeatedly been shown to improve SUD treatment outcomes, countering the common dismissal of nicotine dependence as a lower priority in SUD treatment. However, rates of TDT in this population remain low. Recently, many states have expanded Medicaid coverage of TDT, but it is unclear whether this has increased use of treatment services in this vulnerable group. Tobacco tax and other tobacco control policies have also successfully reduced smoking rates generally, but effectiveness for smokers with SUD is unknown. We propose to assess the impact of expanded TDT coverage and tobacco excise taxes on use of TDT services, smoking intensity and quit rates for smokers with SUD using the 2004-16 Medicaid Analytic Extract (MAX) claims data from all 50 states, and the 2004-2018 National Survey of Drug Use and Health (NSDUH), merged to datasets of state Medicaid benefits and state-, city-, and county-level tobacco policies. Taking advantage of variation within and between states over time, we apply rigorous methods (difference-in- difference analyses and individual fixed-effects models) to assess causal effects of tobacco cessation policies. In Aim 1, we test the effect of Medicaid TDT coverage on initiation and maintenance of TDT and on quitting smoking among Medicaid beneficiaries with SUD. In Aim 2, we test the effect of increasing cigarette excise taxes on the intensity of smoking and smoking cessation in a broader national sample of individuals with SUD. In Aim 3, we assess the combined effects of TDT and tax policies on tobacco use among Medicaid beneficiaries with SUD. We hypothesize that insurance coverage of TDT incentivizes TDT treatment-seeking, that rising taxes create strong incentives to quit, and that both policies together will amplify quitting rates. We have worked closely with stakeholders to propose analyses that inform decision-makers in complex real-world policy environments with hard-to-reach populations, and we incorporate a dissemination plan that lays the groundwork for actionable policy changes by targeting state tobacco control managers, state SUD services agencies, SUD treatment providers reluctant to incorporate TDT, and integrated behavioral health providers.