STRESS AND SMOKING: ASSOCIATIONS WITH TERRORISM AND CAUSAL IMPACT

This study analyzes the effects of the Oklahoma City bombing and 9/11 terrorist attacks on stress, smoking, and smoking quit attempts using 1,657,985 observations from the Behavioral Risk Factor Surveillance System. Regression discontinuity results suggest that, in the fourth quarter of 2001, stress increased by nearly an extra half day per 30 days (11.9%) among ever smoking adults. In the 2 years after 9/11, smoking prevalence increased by 1.1 percentage points (2.3%) among ever smoking adults, resulting in between 950,000 and 1,300,000 adult former smokers becoming smokers again because of terrorism. The net cost to the government was between $530 million and $830 million through the end of 2003. Adults reported disproportionate stress increases based on community military participation and education. Simultaneity between smoking and stress is addressed by an instrumental variables model, providing validity to the hypothesized causal pathway between terrorism, stress, and smoking. This model suggests that an extra day of stress per 30 days causes a 3.4 percentage point increase in smoking among ever smoking adults. Results help to quantify a hidden cost of terrorism and provide a better understanding of utility maximization during periods of high stress. (JET, 112, 118) I. INTRODUCTION The costs of tobacco use in the United States are large. Tobacco use remains the highest preventable cause of disease and death in the United States, each year causing approximately 443,000 deaths and 5.1 million lost years of potential life (CDC 2008). Additionally, tobacco use exacts approximately $157 billion in annual economic losses from the country, and the direct costs attributable to smoking comprise 6-9% of the total national health care budget (U.S. DHHS 2004). Stress motivates smoking. A source of stress that has received much attention recently in the United States is terrorism. This study investigates the possibility that the Oklahoma City bombing and the attacks on September 11, 2001 ("9/11") caused a large increase in stress and smoking as individuals attempted to reduce stress with a perceived stress-reducing commodity. Additionally, this study examines the causal impact of stress on smoking by using 9/11 as a source of exogenous variation. Finally, this study provides net costs to society of terrorism-induced smoking. II. BACKGROUND Recent terrorist attacks in the United States include the April 19. 1995 Oklahoma City bombing, which killed 168 people, and 9/11, which killed 2,937 people in New York City and Washington, D.C. The literature provides compelling evidence that terrorism increases stress and consequently creates health problems. In Colombia, longitudinal data showed a causal relationship between terrorism-provoked stress and lower birth weights for fetuses carried by women who lived near a terrorist attack during their first trimester of pregnancy (Camacho 2008). In the United States, similar stress-induced birth outcomes were associated with 9/11 in New York City and nationwide (Bruckner, Catalano, and Ahern 2010; Lipkind et al. 2010). Several studies found that proximity to the 9/11 epicenters was disproportionately associated with increases in stress (Schlenger et al. 2002; Schuster et al. 2001; Smith et al. 1999; Stein et al. 2004). The 9/11 terrorist attacks were also associated with decreased cardiovascular health in several cities across the United States (Holman et al. 2008; Shedd et al. 2004). Collectively, these studies highlight the magnitude of stress felt from 9/11 and the national, not strictly local, nature of this stress. When disaster strikes, risk perceptions can change and generate secondary social and economic consequences. As an example, a study using commercial vehicles as a control group found that 9/11 contributed to an extra 2,300 noncommercial traffic fatalities because of people substituting long car trips for plane travel (Blalock, Kadiyali, and Simon 2009). …