Perceptions of plain packaging and health warnings among university students in Turkey: a survey-based experiment.

BACKGROUND: Cigarette pack design plays a crucial role in attracting customers, especially when other marketing methods are limited by policy. University students who engage in casual smoking take the risk of developing an addiction. The objective of this study was to assess the effects of plain packaging (PP) and graphic health warnings (GHWs) on cigarette packages on three outcome variables (negative affect, avoidant responses, and intentions to quit) among ever-smoker university students in Ankara, Turkey, where youth smoking prevalence is high. METHODS: An online survey-based experiment was used to collect data. The respondents were randomly assigned to one of the five conditions that contained images of cigarette packs with specific design elements. Regression analyses (n = 623) were used to compare across conditions and to estimate the effects of combined warnings (versus text-only warnings), stronger GHWs (versus old GHWs), and PP (versus branded packages) on the outcome variables, accounting for potential confounders. RESULTS: Stronger GHWs generated more negative affect (0.31 points out of 5, p = 0.010) and avoidant responses (0.42 points out of 5, p = 0.002) than old warnings (when brand logos were visible). Plain packages generated more negative affect (0.48 points out of 5, p < 0.001) and avoidant responses (0.46 points out of 5, p = 0.001) than branded packages (with old warnings). Disentangling the effects of PP and new GHWs revealed that neither had individual differential effect on intentions to quit within 6 months. CONCLUSIONS: Although no differential effect of PP or harsher GHWs was found on intentions to quit when respondents were exposed to images on screen, both design elements were found to be effective in generating negative affect and avoidant responses. More work is needed to design effective tobacco control measures among youth during critical years of tertiary education.

Water pipe smoking among public versus private university students in Ankara, Turkey: an online survey.

BACKGROUND: Water pipe smoking has become a global public health problem as its popularity increased over time, especially among youth. The objective of our study was to estimate water pipe tobacco smoking prevalence and to assess socioeconomic factors associated with ever water pipe smoking by public and private university students in Ankara, Turkey. METHODS: This descriptive study was based on a survey conducted among public (n=2685) and private (n=2485) university students via an online questionnaire on demographics and water pipe consumption patterns. For every student in the sample, a socioeconomic status index was calculated using principal component analysis. Binary logistic regressions for the outcome variable of ever-using water pipe yielded estimates of adjusted odds ratios (aORs) for the associated factors such as the respondent's age, gender, university type, and socioeconomic status. RESULTS: The prevalence of ever use of water pipe was 69.1% (95% CI: 67.2-70.9%) among private and 59.1% (95% CI: 57.2-60.9%) among public university students. A substantial share of ever users were current users (25.5% in private versus 21.6% in public, p=0.008). On average, private university students had higher socioeconomic status than public university students (for example, access to a car (51.7% versus 35.8%, p=0.008), financial support from family (71.5% versus 65.1%, p<0.001)), also demonstrated by a higher socioeconomic status index. Being a private university student (aOR 1.57, 95% CI: 1.38-1.79), older (aORs 1.50 to 2.39, p<0.001), male (aOR 2.36, 95% CI:2.06-2.70), as well as having greater financial resources, such as having access to a car (aOR 1.24, 95% CI:1.07-1.42), or having income support from family (aOR 1.32, 95% CI:1.13-1.54), were associated with ever-using water pipe. A higher SES index was significantly associated with higher odds of ever using water pipe among both private (aOR 1.13, 95% CI:1.06,1.20) and public university (aOR 1.12, 95% CI:1.06,1.19) students. CONCLUSIONS: Water pipe smoking was common in both public and private universities; however, private university students had higher odds of ever using water pipe. There is an urgent need to implement evidence-based interventions, taking into account the socioeconomic status of young adults, to prevent them from water pipe smoking.

Utilization of health-care services by young children: The aftermath of the Turkish Health Transformation Program.

The Turkish Health Transformation Program, initiated in 2003, has identified achieving universal access to health care as 1 of its main tenets. To date, substantial progress has been made toward universal health coverage. Service utilization statistics display an upward trend. In this study, we use official and nationally representative microdata collected by the Turkish Health Research Surveys to examine young children's (ages 0-5) utilization of health services. Children in this age group deserve special attention because adverse health conditions in early childhood are known to have long-time consequences. Policy makers regularly monitor statistics such as infant mortality rate and under-5 mortality rate. We conduct logistic regression analyses to explain the probabilities of being taken to a health institution, to a dentist, and being included in the newborn screening program. We use a rich set of explanatory variables that represent the socioeconomic status (SES) of the child's household. Contrary to our expectations and to the goals of universal health coverage is SES indicators such as the insurance ownership of the parent matter for utilization. Decomposition analyses confirm these findings and reveal that the increase in utilization should have been higher than observed. Children from low SES households should be given special attention and that research efforts should focus on identifying the barriers that still hinder children's utilization of health-care services.

Relative income concerns and smoking behaviour: The role of unobserved heterogeneity.

Status or relative concerns (as in the idiom 'keeping up with the Joneses') can lead to negative feelings such as stress and anxiety. One key question is whether these concerns relate to daily smoking behaviour. The conjecture is that status concerns and the accompanying stress and anxiety might be associated with a higher likelihood of smoking and a higher number of cigarettes smoked, generating a higher instant physical reward and reducing the stress and anxiety. The literature aiming to identify this relationship focuses mostly on a single cross section of individuals, ignoring potential differences in unobserved characteristics of smokers and non-smokers (e.g., genetic factors, personality differences, parental smoking during childhood). This paper investigates the role of unobserved individual characteristics on this relationship, which has not been done in previous studies. Using a long panel data of smoking information in Germany and a variety of panel data model specifications, we show that there is no statistically significant association between relative income concerns and the likelihood of smoking or the number of cigarettes smoked among the overall population. We find a positive and significant relationship only among people who smoked at least one cigarette in the past. A 10% appreciation in the income of comparable other individuals relates to about 3.5 more cigarettes per month among these people. Importantly, failing to allow for the unobserved influences of smoking leads to three times larger estimates than when using models with unobserved factors correlating to the income and smoking behaviour. The results are robust with respect to alternative assumptions and specifications where we use different functional forms of unobserved heterogeneity, definitions of relative concerns, incomes, and reference groups.

Relative deprivation and its association with health indicators: Lower inequality may not improve health.

This study tested the hypothesis of relative deprivation (RD) to investigate how inequality is associated with health and health related behaviors in a developing country context. Data from two nationally representative surveys in 2010, 2012, and 2014 were used to estimate logit and ordered logit models stratified by sex. RD was calculated based on both income and education, unlike most studies in the earlier literature that relied only on income. All results of the study were found to be robust to alternative reference groups. First, consistent with the earlier literature, RD was found to be positively correlated with indicators of poor health. Secondly, and more interestingly, unlike the results in the earlier RD literature, women with more income or education (and lower RD) were found to be more likely to be current smokers and more likely to consume a higher number of cigarettes. The main policy implication is that reducing inequality can help improve self-rated health indicators, but it will not be sufficient to achieve health policy goals. Unless smoking patterns change, reducing inequalities in income or education among women will not necessarily lead to better health; because smoking is more common among better educated and richer women.

Health Care Services and the Elderly: Utilization and Satisfaction in the Aftermath of the Turkish Health Transformation Program.

With the implementation of the health transformation program, Turkey has gone through substantial changes in its health system in the last decade. This study relies on two nationally representative data sets to investigate health service utilization and satisfaction of the elderly. In particular, it examines the share of elderly who have an unmet need for medical care and who could not afford a medical examination or treatment over the years 2006 to 2015, using data from the Turkish Survey of Income and Living Conditions. It also examines the utilization of health services and satisfaction from these services by the elderly in years 2004 to 2015 using data from the Turkish Life Satisfaction Survey. This study finds that utilization has increased and, coinciding with the introduction of the family medicine system, the percentage of patients choosing primary care facilities has increased. The share of the elderly with unmet need and those who could not afford health care have declined. Notwithstanding, overall satisfaction increased only until 2011-2012. Understanding the utilization and satisfaction of the elderly is important, because along with many other countries, the population is aging in Turkey. In the near future, health care needs of the elderly will have a higher priority on the agenda of policy makers.

An economic analysis of tobacco elimination policies in Turkey.

OBJECTIVE: We aim to evaluate the costs and benefits of various tobacco elimination policies, specifically, an immediate taxation option and eight tax-combined long-term cessation programs. METHODS: We combine demographic projections for the period 2012-2050 with incidence and mortality rates of four major cigarette related diseases, price elasticity of cigarette demand and unit costs of nonprice measures to reduce demand in order to estimate the net present discounted values of policy alternatives. RESULTS: The tax-combined cessation programs yield lower net costs to households and the society when they phase out smoking earlier. However, immediate taxation option is found to be superior, for both households and the society, to all tax-combined cessation programs irrespective of the duration of intervention. While all policies are estimated to yield significant reductions in the expected number of smoking related diseases and deaths, a class-based 20-year intervention is found to be the most effective program. CONCLUSIONS: Although immediate taxation policy and tax-combined class-based 20-year intervention program emerge as the best tobacco elimination policies for the society, more research is needed on assessing the cost-effectiveness, applicability and social desirability of these alternatives and on designing additional policies to overcome their limitations.

Health care expenditures and gross domestic product: the Turkish case.

Our study examines the long-term relationship among per capita gross domestic product (GDP), per capita health expenditures and population growth rate in Turkey during the period 1984-2006, employing the Johansen multivariate co-integration technique. Related previous studies on OECD countries have mostly excluded Turkey-itself an OECD country. The only study on Turkey examines the period 1984-1998. However, after 1998, major events and policy changes that had a substantial impact on income and health expenditures took place in Turkey, including a series of reforms to restructure the health and social security system. In contrast to earlier findings in the literature, we find that the income elasticity of total health expenditures is less than one, which indicates that health care is a necessity in Turkey during the period of analysis. According to our results, a 10% increase in per capita GDP is associated with an 8.7% increase in total per capita health expenditures, controlling for population growth. We find that the income elasticity of public health expenditures is less than one. But, in the case of private health care expenditures, the elasticity is greater than one, meaning that private health care is a luxury good in Turkey.