Health Warnings, Smoking Rules and Smoking Status: A Cross-National Comparison of Turkey and the United States

Introduction: Despite having high smoking rates and bearing the heaviest burden of tobacco-related diseases worldwide, less research is conducted in a global perspective. As an effort addressing this gap, we compare the prevalence and predictors of cigarette smoking status between Turkey and the US. The two countries differ in their level of economic development, which contributes to differences seen in tobacco use prevalence globally. This study has two objectives: 1) Compare prevalence of smoking status (never, current, former) between the United States and Turkey using nationally representative data; 2) Identify predictors of former and never smoking status (compared to current smoking status), including household and vehicle smoking restrictions, health warnings, and tobacco advertising as Health Belief Model (HBM) based independent variables, and explore moderating roles of demographic variables on the associations.

Methods: This study used data from the 2012-2013 National Adult Tobacco Survey (NATS; U.S. sample, N=60,192) and the 2012 Global Adult Tobacco Survey (GATS; Turkey sample, N=9,581). Both surveys collected information on the prevalence of tobacco use, factors that promote or impede tobacco use, and participant demographics and are nationally representative. SAS PROC SURVEYLOGISTIC with a weighted variable was used to estimate the relative contributions of demographics and the HBM based variables of smoking status.

Results: One third (34%) of the U.S. sample reported current smoking, compared to 27% of the Turkey sample. While the U.S. sample had a higher proportion of former smokers compared to Turkey (45% vs 13%), the U.S. sample had a much lower proportion of never smokers compared to the Turkey sample (21% vs 60%). Higher education, not allowing smoking in the vehicle and having seen a health warning all increased the odds of being a never smoker, while older age decreased the odds of never smoking among U.S. adults. On the other hand, female gender, rules against smoking in the home, rules against smoking in the vehicle, seeing a health warning, and exposure to cigarette promotions all increased the odds of never smoking compared to current smoking among Turkish adults. While higher education uniquely predicted never smoking status in the U.S., female gender, smoking rules in the home, exposure to cigarette promotions uniquely predicted never smoking status in Turkey. Country (the U.S. vs. Turkey) significantly moderated the impact of health warning on smoking status.

Implications: It is important to work with partners particularly in low- and middle-income countries (e.g., Turkey) to combat the global tobacco epidemic. In both countries, cessation endeavors should emphasize the importance of not allowing smoking in personal spaces, such as at home and in the vehicle. Additionally, health warnings on cigarette packs can be effective to inform the health risks of smoking. Still, further research is needed to test if pictorial and more comprehensive warnings in Turkey is more effective in communicating the risks of smoking than text-only warnings in the U.S. Implications for tobacco-control policies and constraints to implementing policies will be discussed.