PONE-D-20-01101

Catastrophic health expenditure: A comparative analysis of smoking and non-smoking households in China

PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, this manuscript provides an estimate of the incidence and severity of catastrophic financial impact on households from tobacco use in China. This is particularly interesting given the large total number of tobacco users in China, which contributes substantially to the global burden of disease. This survey is notable for its high response rate and broad geographic range regarding regions in China. I was surprised to see that current smoker households do not have a substantially higher incidence or proportion of catastrophic health expenditures than nonsmoker households, and some of my recommendations for the manuscript may provide better insight into that finding.

1) it would be helpful to have a copy editor review the manuscript to clarify minor issues with the English wording. It was also not easy to understand the difference between mean gap and mean positive gap - the formulas helped but it would be good to reframe these in the text so that it is clear the mean gap is the proportion of CHE for the group analyzed, and the mean positive gap is the proportion of CHE for those experiencing CHE within the group analyzed.

2) it could be clearer which regions are sampled. Instead of naming four regions not included in the sampling frame on page 12, it would be easier to state the 28 regions (first all listed on page 15)

3) I am not totally clear if this is a pooled regression analysis rather than a panel regression analysis that uses the respondents that were in both waves of the survey. I am not sure what was the random effect? I would have thought it was time but then it appeared in the table.

4) As the unit of analysis is a household, a change in a single individual could be counted the same way as 5+ individuals. It may be helpful to see a sensitivity analysis where the costs are adjusted for individuals in the family rather than just using it as a fixed effect. This may help explain the surprising findings that households with current smokers do not have higher costs compared to nonsmoking households.

5) One of the advantages of panel data is to evaluate effects among individuals undergoing transitions. it would be helpful if the study took advantage of the panel data available. Instead of analyzing only 3 categories (non, current, former) there could be analyses of seven categories based on 2011 and 2013 status (non to non, current to current, former to former, non to current, non to former, current to former, former to current). Given the reported rate of missingness, it is unclear how many people are transitioning from one state (nonsmoking/former/current) to another (nonsmoking/former/current). Also understanding these transitions would help explain why nonsmoking and current smoking households both decline between 2011 and 2013 which seems unusual as nonsmoking households can only become smoking households or stay nonsmoking, and not feed into the former category (unless allowed to have someone smoke for a year and then quit before the 2013 survey. The transition states may also help clarify the surprising findings for current smokers, as those who were current smokers in 2011 may have different trajectories for those in 2013 that become former smokers vs those that stay current smokers. Is it that groups transitioning from current to former have the highest proportion and severity of CHE?

6) I am unclear what is a meaningful difference for Table 3.

Reviewer #2: For my review of ``Catastrophic health expenditure: A comparative analysis of smoking and non-smoking households in China'' Please see attachment, which explains my responses to the questions above.

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Reviewer #1: No

Reviewer #2: Yes: Christopher F Baum

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Attachments

Attachment

Submitted filename: PLOSFeb2020.pdf

Catastrophic health expenditure: A comparative analysis of smoking and non-smoking households in China

PONE-D-20-01101R1

Dear Dr. Yang,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Petri Böckerman

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: (No Response)

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: (No Response)

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the revisions. Only minor issue is that for formula 2 for MPG I think the N over the summation sign should be N2 not N1. Second sentence of the Discussion should change "Current and Former..." to "Current and former..."

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Christopher F Baum