Politics, Policies and Health Behaviors: The Case of Tobacco

Though believed to be important, in practice politics is frequently neglected as a “fundamental cause” of health outcomes. While anti-smoking policies are widely viewed as a public health success case, so-called “red” states (Southern/Midwestern states that vote Republican) generally have higher smoking rates than “blue” states (states in the Northeast/West Coast that vote Democratic). This disparity is typically explained by differences in demographic characteristics (red-states are poorer than blue-states). However, the relationship between state political climate and health  may operate through policy mechanisms. We assess how state political context affects the adoption of two tobacco policies and declines in smoking rates using state-level data over a fifteen-year period (1996-2011). A longitudinal dataset was constructed from publicly available data of cigarette excise taxes, indoor smoking policies, state smoking prevalence and demographic characteristics from 1996 to 2011. Political context was measured as state vote share for Republican or Democratic presidential candidates and a validated measure of state political culture. Using repeat measure GEE, we assess the relationship between state political context and state smoking prevalence adjusting for demographic characteristics and state policies. We find that state political culture/climate predicts both cigarette excise taxes and indoor smoking restrictions and that more conservative states have seen lower declines in smoking prevalence but that this relationship is only partly explained by state smoking policies. After adjusting for demographic characteristics, state political climate affects smoking behaviors both indirectly (through policy) and directly (a portion of variation that cannot be explained with reference to specific policies).