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Health Information and Life-Course Smoking Behavior: Evidence from Turkey

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Health Information and Life-Course Smoking Behavior: Evidence from Turkey The European Journal of Health Economics https://doi.org/10.1007/s10198-018-0988-9 ORIGINAL PAPER Health information and life-course smoking behavior: evidence from Turkey Dean R. Lillard1 · Zeynep Önder2 Received: 10 August 2017 / Accepted: 7 June 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract We investigate whether individuals are less likely to start and more likely to quit smoking in years when newspapers publish more articles about the health risks of smoking. With data from 9030 respondents to the 2008 Global Adult Tobacco Survey in Turkey, we construct respondents’ life-course smoking histories back to 1925 and model initiation and cessation deci- sions taken 1925–2008. To measure information, we count articles published in Milliyet, one of Turkey’s major newspapers. Results from linear probability models show that people who have seen more smoking-health risk articles know more about the smoking–health relationship. Holding constant each individual’s information stock, education, place of residence, and the price of cigarettes, we find that, as new information arrives, male and female smokers in all cohorts are significantly more likely to quit and women are less likely to start. Our analysis is one of the first that examines how new information affects smoking decisions while controlling for each individual’s existing stock of information. Keywords Information stock and flow · Initiation · Cessation · Life-course smoking history · Turkey JEL Classification I12 · I18 · I20 Introduction Studies that specifically focus on smoking show that people with greater knowledge of the health risks of smoking are We investigate the role information plays in individual deci- less likely to smoke [11, 14, 16]. sions to initiate and quit smoking cigarettes. The broader Cigarette smoking is an interesting case study, because empirical literature shows that consumers’ knowledge is information about and awareness of the health risks of smok- correlated with their consumption, such as breakfast cereal ing increased dramatically during the twentieth century. [13] and various types of medical services [10, 15, 24]. Between 1954 and 1990, the fraction of survey respond- Others show that exposure to nutrient information advertis- ents who identified smoking as one of the causes of lung ing affects food consumption [25] and smoking cessation cancer rose from around 40% in 1954 to 95% in 1990 [17]. product advertising affects smoking cessation decisions [1]. However, it is not clear what role information played. The smoking prevalence rate of Turkish men started to decline Electronic supplementary material The online version of this only in the 1990s [22], while US men’s smoking prevalence article (https ://doi.org/10.1007/s1019 8-018-0988-9) contains was declining even before information was widely available supplementary material, which is available to authorized users. [5, 20]. Among younger cohorts of US and Turkish women, smoking prevalence rate actually rose as information about * Dean R. Lillard [email protected] health risks of smoking spread [20, 22]. Existing evidence may be biased, because the existing Zeynep Önder [email protected] studies measure information/knowledge people endogenously acquire and because the existing models do not account for 1 Department of Human Sciences, Ohio State University, heterogeneity in people’s stock of information. Hsieh et al. DIW-Berlin, NBER, 1787 Neil Avenue, Columbus, [11] try to control for endogenous production of knowledge, OH 43210, USA but their instruments—whether a respondent participated in 2 Faculty of Business Administration, Bilkent University, anti-smoking activities, agrees with smoking restrictions, Bilkent, 06800 Ankara, Turkey Vol.:(0123456789)1 3 D. R. Lillard, Z. Önder recalls having recently seen anti-smoking advertising, or and foreign tobacco products were banned [27]. In 1984, the was aware of the government’s regulation of smoking— government began to dismantle the monopoly when they are themselves endogenous or may suffer from recall bias. allowed foreign companies export their products to Turkey. Jones and Kirigia [14] jointly estimate the probability that a They granted TEKEL the exclusive right to import, price, woman smokes and the probability she knows that “smoking and distribute foreign and domestic brands until 1986. They has negative consequences”. More recently, Cheng et al. [3] let foreign companies partner with TEKEL to manufac- use the latent variable approach to adjust for the knowledge ture locally in 1986 and establish independent production about health effects of smoking from the 2010 Global Adult facilities in 1991. Although the government never allowed Tobacco Survey in China. Our analysis is closest to Lillard television and radio advertising of tobacco, they let firms [21]. He who uses US data to show that information affects advertise in print media and posters. From 1984 to 1996 the probability smokers quit and that people with different international firms aggressively advertised foreign but not levels of education respond in different ways to changes in domestic brands. Nevertheless, over the next decade, total information flows. With the exception of Lillard [21], these cigarette consumption increased. studies, and the broader literature, lack measures of the flow Over our sample period consumers faced widely vary- of information, either overall or specific to particular indi- ing tobacco control policies. For example, nominal and real viduals. Further existing literature investigates the correlation cigarette prices varied tremendously, because the govern- between smoking behavior and either a person’s information ment changed its taxes on cigarettes and tobacco, while it stock or the flow of (new) information but not both. simultaneously created and tamed inflation [22, 23]. Ciga- We improve on the literature in several ways. First, we rette taxes varied from 44% of their retail price in the 1960s model individual smoking decisions taken over most of the to 82.25% of a pack’s retail price by 2014. twentieth century—when the information landscape changed The government enacted other tobacco control policies dramatically. Second, to our knowledge, ours is the first study sporadically from 1981 to 1996 and thereafter more system- to use longitudinal data to model how information affects atically. These policies include a warning label on cigarette smoking behavior of developing country residents. Third, packages enacted in 1981 and strengthened in 1991 and 1996. most studies investigate smoking participation. We investi- A 1996 tobacco control law that banned advertising, smok- gate separately the decision to start and stop smoking. Fourth, ing in many public places, made it illegal for firms to print ours is one of the first studies to include both the stock and tobacco brand names on non-tobacco products, and to sell cig- flow of information. Finally, we explore whether information arettes and other tobacco products to youth under age 18. In effects are heterogeneous across demographic groups that 2002, the government established an independent agency with plausibly differ in how much they know and how likely they broad authority to regulate tobacco markets. Turkey signed are to be exposed to new information. Our results suggest that the World Health Organization’s Framework Convention on the arrival of information reduces the probability of initiation Tobacco Control in 2004; strengthened the warning label decisions of women in some cohorts and causes smokers of wording and its size on packages in 2005, further restricted both sexes to be significantly more likely to quit. to whom and how firms could market tobacco in 2008, and We next briefly describe the social, economic, and politi- banned smoking in more public places in 2008 and 2009. cal contexts in Turkey over our sample period, describe the tobacco market, and review Turkey’s tobacco control history. In the next section, we describe the data. In the following section, we frame our empirical analysis, and describe the Data models and estimation methods. In the next section, we pre- sent results. To conclude, we interpret our results and point Data on smoking and demographics to directions that future research might take and possible policy implications. We draw data on individual smoking behavior from 9,030 respondents to the 2008 Global Adult Tobacco Survey in Tur- key [9]. The nationally representative sample of adults aged Background on tobacco consumption 15 and older provided demographic data, answered questions on contemporaneous and retrospective smoking behavior, and Turkey is an interesting case study. Between 1925 and 2008, whether they know the relationship between smoking and the tobacco market and tobacco taxes changed dramatically, smoking-related illnesses (Turkish Ministry of Health 2010). the economy expanded, per capita income rose, and smoking Tables 1 and 2 report time-invariant demographic char- prevalence of successive Turkish cohorts of men and women acteristics, smoking behavior, and knowledge of the smok- rose and fell (see Fig. 1). Until 1984, Turkey’s tobacco ing-health relationship (including the single factor from the industry operated as a state-owned monopoly called TEKEL principal component analysis). Relative to men, Turkish 1 3 Health information and life-course smoking behavior: evidence from Turkey Fig. 1 Smoking prevalence rates over the life-course by gender and birth cohort. Source: Önder [22] women attain
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