Influence of Risk Perception on Attitudes and Norms Regarding Electronic Cigarettes

The use of electronic cigarettes has grown substantially over the last few years. Currently, about 4% of adults use electronic cigarettes, about 16% of high school students report use in the past 30 days, as do approximately 11–25% of college students. A hallmark of the reduction in tobacco use has been the shift in social norms concerning smoking in public. Such norms may also drive views on acceptability of public electronic cigarette use. While normative factors have been given attention, little substantive application of the literature on risk perception has been brought to bear. The overall aim of this study was to place a cognitive–affective measure of risk perception within a model that also includes social cues for e‐cigarettes, addictiveness beliefs, and tobacco use to predict perceived social acceptability for public use of e‐cigarettes. To do so, a cross‐sectional study using an online survey was conducted among a sample of undergraduate students at a Western university (n = 395). A structural equation model showed that the acceptability of public e‐cigarette use was influenced by social cues, beliefs about addiction, and cognitive risk perception, even after controlling for nicotine use. What is revealed is that cognitive assessment of e‐cigarette risk and perception of addictiveness had a suppressing effect on perceived acceptability of public vaping, while greater exposure to social cues exerted a countervailing effect. This is evidence of the role that risk perception and social norms may play in the increases in electronic cigarette use that have been observed.     

Maximizing Health Benefits and Minimizing Inequality: Incorporating Local‐Scale Data in the Design and Evaluation of Air Quality Policies

The U.S. Environmental Protection Agency undertook a case study in the Detroit metropolitan area to test the viability of a new multipollutant risk‐based (MP/RB) approach to air quality management, informed by spatially resolved air quality, population, and baseline health data. The case study demonstrated that the MP/RB approach approximately doubled the human health benefits achieved by the traditional approach while increasing cost less than 20%—moving closer to the objective of Executive Order 12866 to maximize net benefits. Less well understood is how the distribution of health benefits from the MP/RB and traditional strategies affect the existing inequalities in air‐pollution‐related risks in Detroit. In this article, we identify Detroit populations that may be both most susceptible to air pollution health impacts (based on local‐scale baseline health data) and most vulnerable to air pollution (based on fine‐scale PM_2.5 air quality modeling and socioeconomic characteristics). Using these susceptible/vulnerable subpopulation profiles, we assess the relative impacts of each control strategy on risk inequality, applying the Atkinson Index (AI) to quantify health risk inequality at baseline and with either risk management approach. We find that the MP/RB approach delivers greater air quality improvements among these subpopulations while also generating substantial benefits among lower‐risk populations. Applying the AI, we confirm that the MP/RB strategy yields less PM_2.5 mortality and asthma hospitalization risk inequality than the traditional approach. We demonstrate the value of this approach to policymakers as they develop cost‐effective air quality management plans that maximize risk reduction while minimizing health inequality.     

Climate Change and Human Health: Estimating Avoidable Deaths and Disease

Human population health has always been central in the justification for sustainable development but nearly invisible in the United Nations Framework Convention on Climate Change negotiations. Current scientific evidence indicates that climate change will contribute to the global burden of disease through increases in diarrhoeal disease, vector-borne disease, and malnutrition, and the health impacts of extreme weather and climate events. A few studies have estimated future potential health impacts of climate change but often generate little policy-relevant information. Robust estimates of future health impacts rely on robust projections of future disease patterns. The application of a standardized and established methodology has been developed to quantify the impact of climate change in relation to different greenhouse gas emission scenarios. All health risk assessments are necessarily biased toward conservative best-estimates of health effects that are easily measured. Global, regional, and national risk assessments can take no account of irreversibility, or plausible low-probability events with potentially very high burdens on human health. There is no "safe limit" of climate change with respect to health impacts as health systems in some regions do not adequately cope with the current climate variability. Current scientific methods cannot identify global threshold health effects in order for policymakers to regulate a "tolerable" amount of climate change. We argue for the need for more research to reduce the potential impacts of climate change on human health, including the development of improved methods for quantitative risk assessment. The large uncertainty about the future effects of climate change on human population health should be a reason to reduce greenhouse gas emissions, and not a reason for inaction.     

Quantitative Assessment of Human MRSA Risks from Swine

The public health community, news media, and members of the general public have expressed significant concern that methicillin‐resistant Staphylococcus aureus (MRSA) transmitted from pigs to humans may harm human health. Studies of the prevalence and dynamics of swine‐associated (ST398) MRSA have sampled MRSA at discrete points in the presumed causative chain leading from swine to human patients, including sampling bacteria from live pigs, retail meats, farm workers, and hospital patients. Nonzero prevalence is generally interpreted as indicating a potential human health hazard from MRSA infections, but quantitative assessments of resulting risks are not usually provided. This article integrates available data from several sources to construct a conservative (plausible upper bound) probability estimate for the actual human health harm (MRSA infections and fatalities) arising from ST398‐MRSA from pigs. The model provides plausible upper bounds of approximately one excess human infection per year among all U.S. pig farm workers, and one human infection per 31 years among the remaining total population of the United States. These results assume the possibility of transmission events not yet observed, so additional data collection may reduce these estimates further.     

CSP Deposition to the Alveolar Region of the Lung: Implications of Cigarette Design

Ventilated cigarettes were designed to reduce the levels of smoke under machine testing conditions; however, smokers alter their smoking pattern to compensate for the reduction in yields. A relative shift in incidence of lung cancer from the more central lung airways to the alveolar region has also been associated with ventilated cigarette use. Validated mathematical models indicate that particle deposition patterns in the lung depend on particle size and inhalation behavior, including inhalation volume, flow rate, and breath-hold time. This article finds that most mathematical models underpredict total cigarette smoke particulate (CSP) deposition in the lung, likely because they do not account for coagulation, hygroscopicity, and cloud dynamics, which may increase the effective particle diameter of CSP reaching the lung tissue. The models that include these processes indicate that puff volume would be unlikely to affect particle deposition in the lung, but puff time, inhalation depth, breath-hold time, and exhalation time may affect total deposition. Most compensation appears to occur through a combination of increased puff volume and puff flow, with possible increases in inhalation depth and breath-hold time. The complex interaction between the extent of cigarette ventilation, which can affect puffing/inhalation behavior, CSP concentration, and CSP size with CSP dose to the alveolar versus more central lung airways is described. Deposition efficiency in the alveoli could plausibly be increased through compensation, but it is still unclear whether compensation could sufficiently alter patterns of CSP deposition in the lung to elicit a shift in lung cancer sites.     

Cigarette Smoking and Multiple Health Risk Behaviors: A Latent Class Regression Model to Identify a Profile of Young Adolescents

Cigarette smoking is often established during adolescence when other health‐related risk behaviors tend to occur. The aim of the study was to further investigate the hypothesis that risky health behaviors tend to cluster together and to identify distinctive profiles of young adolescents based on their smoking habits. To explore the idea that smoking behavior can predict membership in a specific risk profile of adolescents, with heavy smokers being more likely to exhibit other risk behaviors, we reanalyzed the data from the 2014 Health Behaviour in School‐Aged Children Italian survey of about 60,000 first‐ and third‐grade junior high school (JHS) and second‐grade high school (HS) students. A Bayesian approach was adopted for selecting the manifest variables associated with smoking; a latent class regression model was employed to identify smoking behaviors among adolescents. Finally, a health‐related risk pattern associated with different types of smoking behaviors was found. Heavy smokers engaged in higher alcohol use and abuse and experienced school failure more often than their peers. Frequent smokers reported below‐average academic achievement and self‐rated their health as fair/poor more frequently than nonsmokers. Lifetime cannabis use and early sexual intercourse were more frequent among heavy smokers. Our findings provide elements for constructing a profile of frequent adolescent smokers and for identifying behavioral risk patterns during the transition from JHS to HS. This may provide an additional opportunity to devise interventions that could be more effective to improve smoking cessation among occasional smokers and to adequately address other risk behaviors among frequent smokers.     

Diminishing Willingness to Pay per Quality‐Adjusted Life Year: Valuing Acute Foodborne Illness

We design and conduct a stated‐preference survey to estimate willingness to pay (WTP) to reduce foodborne risk of acute illness and to test whether WTP is proportional to the corresponding gain in expected quality‐adjusted life years (QALYs). If QALYs measure utility for health, then economic theory requires WTP to be nearly proportional to changes in both health quality and duration of illness and WTP could be estimated by multiplying the expected change in QALYs by an appropriate monetary value. WTP is elicited using double‐bounded, dichotomous‐choice questions in which respondents (randomly selected from the U.S. general adult population, n = 2,858) decide whether to purchase a more expensive food to reduce the risk of foodborne illness. Health risks vary by baseline probability of illness, reduction in probability, duration and severity of illness, and conditional probability of mortality. The expected gain in QALYs is calculated using respondent‐assessed decrements in health‐related quality of life if ill combined with the duration of illness and reduction in probability specified in the survey. We find sharply diminishing marginal WTP for severity and duration of illness prevented. Our results suggest that individuals do not have a constant rate of WTP per QALY, which implies that WTP cannot be accurately estimated by multiplying the change in QALYs by an appropriate monetary value.     

THE EFFECT OF MASCULINE AND FEMININE BRAND NAMES ON THE PERCEIVED TASTE OF A CIGARETTE *

The purpose of the current study was to determine whether brand name can affect the public's evaluation of a product. All subjects smoked identical cigarettes. One group of subjects, however, knew the cigarettes by the name of “Frontiersman,” a masculine name, while the other group knew the cigarettes as “April,” a feminine name. Male and female subjects were asked to rate the cigarette on seven measures. Results show that women gave a more positive evaluation to the cigarette purportedly named “April,” while men gave a more positive evaluation to the identical cigarette when they thought it was named “Frontiersman.” In addition, women reacted more strongly than did men to brand name influence.     

Uncertainties in the Link Between Global Climate Change and Predicted Health Risks from Pollution: Hexachlorobenzene (HCB) Case Study Using a Fugacity Model

Industrial societies have altered the earth's environment in ways that could have important, long-term ecological, economic, and health implications. In this paper, we examine the extent to which uncertainty about global climate change could impact the precision of predictions of secondary outcomes such as health impacts of pollution. Using a model that links global climate change with predictions of chemical exposure and human health risk in the Western region of the United States of America (U.S.), we define parameter variabilities and uncertainties and we characterize the resulting outcome variance. As a case study, we consider the public health consequences from releases of hexachlorobenzene (HCB), a ubiquitous multimedia pollutant. By constructing a matrix that links global environmental change both directly and indirectly to potential human-health effects attributable to HCB released into air, soil, and water, we define critical parameter variances in the health risk estimation process. We employ a combined uncertainty/sensitivity analysis to investigate how HCB releases are affected by increasing atmospheric temperature and the accompanying climate alterations that are anticipated. We examine how such uncertainty impacts both the expected magnitude and calculational precision of potential human exposures and health effects. This assessment reveals that uncertain temperature increases of up to 5°C have little impact on either the magnitude or precision of the public-health consequences estimated under existing climate variations for HCB released into air and water in the Western region of the U.S.     

基于理性依赖理论的吸烟与居民医疗保健支出研究

根据Becker-Murphy(1988)和Chaloupka(1991)理性依赖行为理论推导的医疗保健支出模型表明,卷烟消费及其依赖性对居民医疗保健支出具有重要影响.采用1997～2002年相关数据进行的实证分析显示,卷烟消费及其依赖性与居民医疗保健支出正相关,且后者的影响更大更为显著.提高目前偏低的卷烟税率既能弥补吸烟的负外部性,也能有效地促进公共健康.     

Informal leadership support: an often overlooked competitive advantage

As environmental pressures mount, the advantage of using the same strategies and tactics employed by competitors continues to shrink. An alternative is adapting and applying answers successfully employed in other industries to health care organizations. Working with informal influence leaders to share your change management efforts represents one such example. Informal influence leaders offer an often-overlooked source of competitive advantage--they have already earned credibility and respect from others, who regularly look to them for guidance. When sharing their views, they significantly influence the acceptance or rejection of new initiatives. Influence leaders reach into every conversation, every meeting, and every decision made in an organization. The important question is whether they will exert their leadership in support or in opposition to changes you propose. By identifying influence leaders and inviting them to join a group to discuss change initiatives, physician executives can create a positive force for change.     

A Comparison of Egg Consumption with Other Modifiable Coronary Heart Disease Lifestyle Risk Factors: A Relative Risk Apportionment Study

Guidelines from the American Heart Association (AHA) recommend that healthy adults limit their intake of dietary cholesterol to less than 300 mg per day. Since a large egg contains about 71% of that amount, the AHA recommends restricting egg consumption unless dietary cholesterol intakes from other sources are limited. We applied a risk apportionment approach to estimate the contribution of egg consumption and other modifiable lifestyle risk factors (e.g., smoking, poor diet, minimal exercise, and alcohol intake) to coronary heart disease (CHD) risk at the population level. Specifically, we categorized the U.S. adult population ages 25+ into distinct risk groups based on the prevalence of modifiable lifestyle risk factors and applied an apportionment model, typically used to assess risk contribution at the individual level, to estimate the contribution of egg intake to CHD risk. Our analysis shows that the combination of modifiable lifestyle risk factors accounts for less than 40% of the population CHD mortality. For the majority of U.S. adults age 25+, consuming one egg a day accounts for <1% of CHD risk. Hence, focusing on decreasing egg intake as an approach to modify CHD risk would be expected to yield minimal results relative to changing other behaviors such as smoking and other dietary habits.     

Managing Potential Health Risks from Electric Powerlines: A Decision Analysis Caught in Controversy

Over the past 20 years, several epidemiological studies have found an association between exposure to electromagnetic fields (EMFs) and health effects, including childhood leukemia and adult brain cancer. However, experts strongly disagree about whether this association is causal and, if so, how strong it is. In this article, we examine several alternatives to reduce EMFs from sources of the California power grid, including undergrounding distribution and transmission lines and reconfiguring or rephasing lines. The alternatives were evaluated in terms of the potential health risk reduction, cost, impacts on service reliability, property values, and many other consequences. Because of the uncertainty about an EMF-health link, the main effort was to determine the sensitivity of the decisions to the probability and seriousness of an EMF hazard. User-friendly computer models were developed to allow stakeholders to change the model assumptions and parameters to analyze the impacts of their own assumptions and estimates on the decision. The analysis clearly demonstrated that only four of the many concerns raised by the stakeholders could make a difference in the decision: health risks, costs, service reliability, and property values. Whether undergrounding, moderate alternatives for EMF reduction, or no change was the best decision depended on a few key factors, including the probability that EMF exposure is a hazard, the severity of this hazard, how the EMF reduction measures are financed, and the impacts on property values. While the analysis did not resolve the EMF issues, it showed that even in the most controversial settings, a little analysis goes a long way to clarifying the issues and to focus the debate.     

Total Economic Consequences of an Influenza Outbreak in the United States

Pandemic influenza represents a serious threat not only to the population of the United States, but also to its economy. In this study, we analyze the total economic consequences of potential influenza outbreaks in the United States for four cases based on the distinctions between disease severity and the presence/absence of vaccinations. The analysis is based on data and parameters on influenza obtained from the Centers for Disease Control and the general literature. A state‐of‐the‐art economic impact modeling approach, computable general equilibrium, is applied to analyze a wide range of potential impacts stemming from the outbreaks. This study examines the economic impacts from changes in medical expenditures and workforce participation, and also takes into consideration different types of avoidance behavior and resilience actions not previously fully studied. Our results indicate that, in the absence of avoidance and resilience effects, a pandemic influenza outbreak could result in a loss in U.S. GDP of $25.4 billion, but that vaccination could reduce the losses to $19.9 billion. When behavioral and resilience factors are taken into account, a pandemic influenza outbreak could result in GDP losses of $45.3 billion without vaccination and $34.4 billion with vaccination. These results indicate the importance of including a broader set of causal factors to achieve more accurate estimates of the total economic impacts of not just pandemic influenza but biothreats in general. The results also highlight a number of actionable items that government policymakers and public health officials can use to help reduce potential economic losses from the outbreaks.     

Modeling the Modification of the Risk of Radon-Induced Lung Cancer by Environmental Tobacco Smoke

The presence of environmental tobacco smoke (ETS) in homes has been implicated in the causation of lung cancer. While of interest in its own right, ETS also influences the risk imposed by radon and its decay products. The interaction between radon progeny and ETS alters the exposure, intake, uptake, biokinetics, dosimetry, and radiobiology of those progeny. The present paper details model predictions of the various influences of ETS on these factors in the U.S. population and provides estimates of the resulting change in the risk from average levels of radon progeny. It is predicted that the presence of ETS produces a very small (perhaps unmeasurable) increase in the risk of radiation-induced tracheobronchial cancer in homes with initially very high particle concentrations for both active and never-smokers, but significantly lowers the risk in homes with initially lower particle concentrations for both groups when generation 4 of the lung is considered the target site. For generation 16, the presence of ETS generally increases the radon-induced risk of lung cancer, although the increase should be unmeasurable at high initial particle concentrations. The net effect of ETS on human health is suggested to be a complicated function of the initial housing conditions, the concentration of particles introduced by smoking, the target generation considered, and the smoking status of exposed populations. This situation precludes any simple statements concerning the role of ETS in governing the incidence of lung cancer in a population.     

Characterizing Environmental Harm: Developments in an Approach to Strategic Risk Assessment and Risk Management

Environmental policymakers and regulators are often in the position of having to prioritize their actions across a diverse range of environmental pressures to secure environmental protection and improvements. Information on environmental issues to inform this type of strategic analysis can be disparate; it may be too voluminous or even absent. Data on a range of issues are rarely presented in a common format that allows easy analysis and comparison. Nevertheless, judgments are required on the significance of various environmental pressures and on the inherent uncertainties to inform strategic assessments such as “state of the environment” reports. How can decisionmakers go about this type of strategic and comparative risk analysis? In an attempt to provide practical tools for the analysis of environmental risks at a strategic level, the Environment Agency of England and Wales has conducted a program of developmental research on strategic risk assessment since 1996. The tools developed under this program use the concept of “environmental harm” as a common metric, viewed from technical, social, and economic perspectives, to analyze impacts from a range of environmental pressures. Critical to an informed debate on the relative importance of these perspectives is an understanding and analysis of the various characteristics of harm (spatial and temporal extent, reversibility, latency, etc.) and of the social response to actual or potential environmental harm from a range of hazards. Recent developments in our approach, described herein, allow a presentation of the analysis in a structured fashion so as to better inform risk‐management decisions.     

Risk‐Taking and the Media

In recent years, media formats with risk‐glorifying content, such as video games that simulate illegal street racing (“bang and crash” games), films about extreme sports, and risky stunts have emerged as top sellers of the media industry. A variety of recent studies conducted by several researchers revealed that exposure to risk‐glorifying media content (e.g., video games that simulate reckless driving, smoking and drinking in movies, or depictions that glorify extreme sports) increases the likelihood that recipients will show increased levels of risk‐taking inclinations and behaviors. The present article (1) reviews the latest research on the detrimental impact of risk‐glorifying media on risk‐taking inclinations (cognitions, emotions, behaviors), (2) puts these findings in the theoretical context of recent sociocognitive models on media effects, and (3) makes suggestions to science and policymakers on how to deal with these effects in the future.     

Care management challenge is the toughest yet.

The newest health care trend involves changing the core business--health care delivery and the resources involved--through better care management. This impacts every practitioner all day, every day. This issue truly belongs to the physicians, and thus to physician executives. Care management is the latest frontier, the place where the delivery of quality care, in the most efficient way, at the best possible cost, all come together. And physician executives are being challenged to make it happen, to change the way medicine is practiced and health care is delivered across the country, to move from treating episodes of care to a true preventive mindset and population-based methodologies. This column outlines the skills in care management that systems-based physician executives will need to develop or enhance to remain competitive--effective communication skills and team-building capabilities are critical attributes for those who hope for success.     

Quantifying Potential Health Impacts of Cadmium in Cigarettes on Smoker Risk of Lung Cancer: A Portfolio-of-Mechanisms Approach

This article introduces an approach to estimating the uncertain potential effects on lung cancer risk of removing a particular constituent, cadmium (Cd), from cigarette smoke, given the useful but incomplete scientific information available about its modes of action. The approach considers normal cell proliferation; DNA repair inhibition in normal cells affected by initiating events; proliferation, promotion, and progression of initiated cells; and death or sparing of initiated and malignant cells as they are further transformed to become fully tumorigenic. Rather than estimating unmeasured model parameters by curve fitting to epidemiological or animal experimental tumor data, we attempt rough estimates of parameters based on their biological interpretations and comparison to corresponding genetic polymorphism data. The resulting parameter estimates are admittedly uncertain and approximate, but they suggest a portfolio approach to estimating impacts of removing Cd that gives usefully robust conclusions. This approach views Cd as creating a portfolio of uncertain health impacts that can be expressed as biologically independent relative risk factors having clear mechanistic interpretations. Because Cd can act through many distinct biological mechanisms, it appears likely (subjective probability greater than 40%) that removing Cd from cigarette smoke would reduce smoker risks of lung cancer by at least 10%, although it is possible (consistent with what is known) that the true effect could be much larger or smaller. Conservative estimates and assumptions made in this calculation suggest that the true impact could be greater for some smokers. This conclusion appears to be robust to many scientific uncertainties about Cd and smoking effects.