Social Inequalities In Smoking Research Articles

School tobacco policies and social inequalities in adolescent smoking

Abstract Background Adolescents of lower socio-economic status initiate smoking earlier and smoke more frequently than those of higher socio-economic status. Tobacco control policies, such as school tobacco policies, aim to reduce adolescent smoking, but their implementation has been found to vary greatly from one school to another. Such differences in the implementation might therefore contribute to social inequalities in smoking. This study examines whether school tobacco policies are implemented where they are most needed, and how this implementation according to needs has changed over time. Methods Student (n = 18,805) and staff surveys (n = 438) were conducted in 2013 and 2016 in 38 schools from six European cities in six countries. School tobacco policies were measured as a 10-point score taking into account their multidimensionality, and the perceptions of both students and staff. We used concentration curves and indices to measure the inequality in the implementation of these policies depending on the smoking prevalence and on adolescents’ socio-economic status. Results A concentration curve below the perfect equity line indicated a concentration of school tobacco policies where smoking prevalence was lower. Moreover, this inequality was larger in 2016 compared to 2013 (concentration indices of .038 in 2013 and .041 in 2016). On the contrary, a concentration curve overlaying the perfect equity line indicated no inequality in the implementation of these policies depending on adolescents’ socio-economic status (concentration indices of .016 in 2013 and -.013 in 2016). Conclusions School tobacco policies have been developed to reduce adolescent smoking. They, however, seem to be less implemented in schools where they are most needed. This confirms that smoking prevention is still driven by the inverse prevention law. Next to evaluating the impact of such policies on smoking outcomes, research should also focus on their contribution to social inequalities in adolescent smoking. Key messages • School tobacco policies, developed to reduce adolescent smoking, might contribute to social inequalities in smoking. • School tobacco policies are less implemented where they are most needed.

How do educational disparities in smoking develop during early life? A Swedish longitudinal study

Smoking contributes to health inequalities, but how social inequalities in smoking develop in early life remains unclear. This study examines how measures of education attained over the early life course (representing socioeconomic position of origin, socioeconomic position of destination, and in-between) contribute to smoking behavior in a Swedish longitudinal sample. We used data obtained from the Swedish Level-of-Living Surveys in addition to national register data. Young adults (aged 20–28, n = 749) self-reported their educational attainment and smoking behavior (initiation and cessation) in 2010. Ten years earlier, their parents self-reported their own education and smoking behavior. We used linked register data on school performance in adolescence (in grade 9). Logistic regression models showed that lower parental education, lower adolescent school performance, and low young adult educational attainment were respectively associated with young adult smoking initiation. The association between parental education and young adult smoking initiation was explained by adolescent school performance and not parental smoking. Young adult smoking cessation was associated with high parental education and high adolescent school performance (marks in the top quartile), but only school performance remained significant in the final model, which included all measures of education and parental smoking. Results suggest that school performance in adolescence (which connects adolescents’ socioeconomic position of origin with their destination) may play an important role in how educational disparities in smoking form over the life course.

Do social inequalities in smoking differ by immigration status in young adults?

Abstract Background Tobacco use accounts for half the difference in life expectancy across groups of low and high socioeconomic status. The objective was to assess whether social inequalities in smoking in Canada-born young adults are also apparent among same-age immigrants, a group often viewed as disadvantaged and vulnerable to multiple health issues. Methods Data were drawn from the Interdisciplinary Study of Inequalities in Smoking, a longitudinal investigation of social inequalities in smoking in Montreal, Canada. The sample included 2,077 young adults age 18-25 (56.6% female; 18.9% immigrants). Immigrants had been in Canada 11.6 (SD 6.4) years on average. The association between level of education and current smoking was examined separately in immigrants and non-immigrants in multivariate logistic regression analyses controlling for covariates. Results Twenty percent of immigrants were current smokers compared to 24% of non-immigrants. In immigrants, relative to those who were university-educated, the adjusted odds ratio (OR) (95% confidence interval) for current smoking was 1.2 (0.6, 2.3) among those with pre-university or vocational training, and 1.5 (0.7, 2.9) among those with high school education only. In non-immigrants, the adjusted ORs were 1.9 (1.4, 2.5) among those with pre-university or vocational training and 4.0 (2.9, 5.5) among those with high school education. Conclusions Despite a mean of over 10 years in Canada, young adults who immigrated to Canada did not manifest the strong social gradient in smoking apparent in non-immigrants. Identification of factors that protect immigrants from manifesting marked social inequalities in smoking could inform the development of smoking preventive intervention sensitive to social inequalities in smoking. Key messages A social gradient in smoking apparent in Canada-born young adults was not observed in same-age immigrants. Factors that protect immigrants against social inequalities in smoking should be identified.

Tobacco control’s effects on social inequalities in smoking: Moving towards a health equity approach

Abstract Population-level public health policies aim to improve health for the entire population. Yet, in doing so, they may unintentionally neglect vulnerable populations' specific needs, which may perpetuate social inequalities in health. As an example, tobacco control policies (e.g. media campaigns, smoke-free places, tax increases, and tobacco product regulation) have been found to significantly reduce overall smoking prevalence in many high-income countries. However, social inequalities in smoking have been increasing, with smoking prevalence being higher, notably for those of low socio-economic status (SES). Low SES individuals start smoking at younger ages, smoke more cigarettes per day, have lower cessation rates, and are exposed to more second-hand smoke than higher SES individuals. These social inequalities in smoking translate into social inequalities in health such that low SES groups carry a disproportionately heavier burden of smoking-related illnesses. Based on data from a critical discourse analysis of tobacco control policy in Quebec, Canada, as well as from a literature review of vulnerable populations' experiences with tobacco control policies, this presentation will: 1) illustrate ways in which tobacco control policies may be increasing social inequalities in smoking, including the absence of vulnerable populations who smoke from policy planning, smoking denormalization's unintended stigmatizing effects, and targeting behaviours rather than the 'causes of the cause' in policy; 2) provide ideas for future population-level policies based on a health equity approach, which includes integrating vulnerable population's voices in policy design, prioritizing vulnerable populations and health equity in policy, and shifting attention towards policies addressing social inequalities in access to social determinants (e.g. education, income, employment security, safe, clean, and affordable housing) to improve health rather than targeting behaviours, such as smoking.

Social differences in 20-year trends in daily smoking among Lithuanian adult population

Abstract Background Tobacco control measures carried out in the countries can affect social inequalities in the smoking habit. This study aimed to examine the 20-year trends in social patterning of daily smoking in Lithuania. Methods The data were obtained from 11 biannual cross-sectional postal surveys of Lithuanian Health Behaviour Monitoring, beginning in 1994. Each survey used a randomly selected nationally representative independent sample of 3000-4000 inhabitants aged 20-64 drawn from the population register. In total, 8738 men and 11822 women participated in the surveys. The analysis of daily smoking involved the respondents who had smoked daily for at least one year. Results The prevalence of daily smoking was increasing up to the year 2000, especially among women, while a decreasing trend in men and levelling off a trend in women was observed afterwards. In the last survey, 33.3% of men and 12.5% of women were daily smokers. The proportion of daily smokers was higher among younger than older participants; however, the age difference in smoking decreased over time. The highly educated men and women smoked less than those with low education. The odds ratio (OR) of smoking in men with university versus lower education was 0.42 (95% CI 0.37-0.47) and in women - 0.68 (95% CI 0.60-0.78). The proportion of smoking men decreased in all educational groups; however, the differences in the smoking prevalence remained. Since 2000, the educational gradient in smoking among women was increasing due to a decline in smoking prevalence among women with university education. More women living in big cities than in non-urban areas were daily smokers (OR 1.29; 95% CI 1.15-1.44). Over 20 years, no consistent difference in the smoking trends by place of residence was found in both genders. Conclusions The 20-year trends in social patterning of daily smoking differed between men and women. Inequalities in daily smoking by age and education remained in both genders. Key messages In Lithuania, the trends and social differences in daily smoking were related to gender. Comprehensive tobacco control measures targeting young and lower educated groups should be implemented aiming to reduce social inequalities in smoking.

16.E. Workshop: Preventing public health interventions from contributing to social inequalities in health

Abstract Reasons Public health aims to improve the health of populations and reduce social inequalities in health, notably through action on social determinants of health, physical and social environments, public policies, access to health services, and community empowerment. As such, public health has a social agenda and therefore a corresponding social responsibility. However, social inequalities in health continue to be a pressing problem in Canada, as well as around the world. Growing research demonstrates that public health interventions can unintentionally contribute to increasing social inequalities in health by perpetuating social norms that stigmatize vulnerable groups, neglecting the needs of vulnerable groups, and/or replicating power dynamics that reinforce situations which disenfranchise vulnerable populations. Objectives This workshop aims to: 1) discuss how public health interventions can inadvertently contribute to increasing social inequalities in health; 2) explore strategies to develop more equitable interventions. Added value Despite growing research on the unintended contributions of public health interventions in increasing social inequalities in health, this pressing problem remains generally under acknowledged in public health research and practice. Yet in order to reverse these effects, researchers and professionals alike need to become aware of and reflect on the potential impacts of their actions on vulnerable populations. Thus, the presentations in this workshop will provide concrete examples based on innovative research findings and critical reflections of the ways in which public interventions can increase social inequalities in health. We will also suggest health equity-related considerations for future intervention evaluation and design. Coherence The two first presentations will serve to illustrate how public health interventions can increase social inequalities in health and how we might reverse these effects by drawing on examples from tobacco control and health care. Based on these examples, the last presentation will demonstrate how a theoretically-driven framework (i.e. Acting Within Contexts) can be applied for intervention evaluation and future equitable intervention design. Format A brief introduction to present the workshop topic and learning objectives (5 minutes) Three presentations by panelists (10 minutes each; 30 minutes total): The unintended effects of tobacco control policies on social inequalities in smoking: Moving forward with a health equity approach; Equality versus equity: Barriers to health care access for Indigenous populations in Canada; Applying the “Acting Within Contexts” framework to intervention evaluation and equitable intervention design. A plenary discussion with the audience to draw collective lessons (25 minutes) Key messages To raise awareness of the potential unintended effects of public health interventions on increasing social inequalities in health. To better understand how to reduce inequities by integrating the needs and contexts of vulnerable populations in intervention planning.

Do Social Inequalities in Smoking Differ by Immigration Status in Young Adults Living in an Urban Setting? Findings From the Interdisciplinary Study of Inequalities in Smoking.

Objectives:We assessed whether social inequalities in smoking observed among young adults born in Canada were also apparent in same-age immigrants.Methods:Data were drawn from an investigation of social inequalities in smoking conducted in an urban setting (Montreal, Canada). The sample included 2077 young adults age 18 to 25 (56.6% female; 18.9% immigrants who had lived in Canada 11.6 (SD 6.4) years on average). The association between education and current smoking was examined in multivariable logistic regression analyses conducted separately in young adults born in Canada and in immigrants.Results:About 19.5% of immigrants were current smokers compared to 23.8% of young adults born in Canada. In immigrants, relative to those with university education, the adjusted odds ratios (OR) (95% confidence interval) for current smoking were 1.2 (0.6, 2.3) among those with pre-university/vocational training and 1.5 (0.7, 2.9) among those with high school education. In non-immigrants, the adjusted ORs were 1.9 (1.4, 2.5) among those with pre-university/vocational training and 4.0 (2.9, 5.5) among those with high school.Conclusion:Young adults who had immigrated to Canada did not manifest the strong social gradient in smoking apparent in young adults born in Canada. Increased understanding of the underpinnings of this difference could inform development of interventions that aim to reduce social inequalities in smoking.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BackgroundWhile some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.MethodsTen electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.ResultsWe identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.ConclusionsThe only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that – even where NCNP use is higher among low SES groups – this does not necessarily replace smoked tobacco use in these groups.

Young adults' experiences of neighbourhood smoking-related norms and practices: A qualitative study exploring place-based social inequalities in smoking

In this qualitative exploratory study we asked how smoking among young adults relates to the local neighbourhood context to better understand place-based social inequalities in smoking. We used data collected through focus groups with young adults from four economically diverse neighbourhoods in Montreal, Canada. Using the collective lifestyles framework to guide data analysis, we examined within and between neighbourhood social norms, practices, and agency. We found that some smoking-related social norms, practices and agency were particular to neighbourhoods of the same socio-economic status (SES). For example, permissive smoking-related social norms in low-SES neighbourhoods made it difficult to avoid smoking but also reduced local experiences of smoking-related stigma and isolation. In high-SES neighbourhoods, strong anti-smoking norms led to smoking in secret and/or amidst ‘acceptable’ social settings. Findings may inform future investigations and local-level interventions focused on this age group.

Trends in Absolute and Relative Educational Inequalities in Adult Smoking Since the Early 2000s: The Case of Germany.

Since the early 2000s, several tobacco control policies have been implemented in Germany. Current research is inconsistent about how strengthening tobacco control can affect social inequalities in smoking. This study examines whether educational inequalities in adult smoking have widened in Germany since 2003. Data were used from four cross-sectional national health surveys conducted between 2003 and 2012 (n = 54,197; age = 25-69 years). Participants who smoked daily or occasionally were classified as smokers. The regression-based Slope Index of Inequality and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in smoking, respectively. In each survey year, smoking was associated with lower education. Overall, crude and age-standardized smoking rates declined over time. Stratified by education, trends of declining smoking rates were observed only in the high and medium education groups, whereas no statistically significant trend was found in the low education group. Relative educational inequalities in smoking increased significantly in men (2003: RII=1.74, 95% confidence interval 1.46 to 2.07; 2012: RII = 2.25, 95% confidence interval 1.90 to 2.67; p-trend = .019). Absolute educational inequalities in smoking were not found to have changed significantly during the study period. In the course of declining smoking rates, educational inequalities in smoking persisted in both absolute and relative terms. In men, relative inequalities in smoking may even have widened within only 9 years. Tobacco control policies should not only be targeted at the entire population but also attempt to reduce social inequalities in smoking by focusing more on socially disadvantaged groups. Smoking is associated with lower education in most European countries and contributes to social inequalities in health. Since the beginning of the 2000s, Germany has implemented a variety of tobacco control policies to reduce smoking in the population. This study reveals that despite a general decline in adult smoking, educational inequalities in smoking have persisted and even widened in Germany since 2003. The findings emphasize that more targeted efforts are needed to tackle smoking-induced inequalities in health.

Trends in social inequalities in smoking and secondhand smoke exposure among adolescents in Germany

Trends in social inequalities in smoking and secondhand smoke exposure among adolescents in Germany

Can reflexivity be learned? An experience with tobacco control practitioners in Canada.

To explore an example of a reflexive intervention with health professionals working in tobacco control (TC). This study reports the perceived intervention effects regarding: (i) participants' understanding of reflexivity and personal learning and (ii) conditions needed in order to integrate reflexivity into professional and organizational practices. This is a qualitative study using an interpretative evaluation framework to assess the perceived effects of a reflexive intervention in Montréal, Québec. Semi-structured qualitative interviews (n = 8) gathered data. Data analysis began deductively, guided by the broad categories found in research questions. Sub-categories to populate these broad categories captured the inhibitors and facilitators through an inductive thematic analysis. Our study reveals that, following the intervention, most participants had a generally good understanding of reflexivity and described concrete learning in association with the intervention. Main facilitators and inhibitors to conducting a reflexive workshop pertained to the organizational context as well as to the professional and individual characteristics of the participants. Some participants implemented sustainable changes as a result of the intervention, such as creating a tool, reviewing work plans and developing new mechanisms to integrate the voice of their clientele in the planning process. The need and interest for dialogue among health professionals about how TC intervention activities may inadvertently contribute to social inequalities in smoking is apparent. While there appears to be potential for reflexive practice, the integration of reflexivity into practice is reliant upon the organizational context (financial and time constraints, culture, support, and climate) and the reflexivity concept itself (intangibility, complexity and fuzziness).

Social capital and adolescent smoking in schools and communities: A cross-classified multilevel analysis

We sought to determine whether social capital at the individual-, school- and community-level can explain variance in adolescent smoking and accounts for social inequalities in smoking. We collected data as part of the 2005/6 Health Behavior in School-aged Children survey, a nationally representative survey of the health and well-being of high school pupils in Belgium (Flanders). Social capital was assessed by structural and cognitive components of family social capital, a four-factor school social capital scale and a cognitive community social capital scale. We fitted non-hierarchical multilevel models to the data, with 8453 adolescents nested within a cross-classification of 167 schools and 570 communities. Significant variation in adolescent regular smoking was found between schools, but not between communities. Only structural family social capital and cognitive school social capital variables negatively related to regular smoking. No interactions between socio-economic status and social capital variables were found. Our findings suggest that previously observed community-level associations with adolescent smoking may be a consequence of unmeasured confounding. Distinguishing nested contexts of social capital is important because their associations with smoking differ.

State-level tobacco environments and sexual orientation disparities in tobacco use and dependence in the USA

ObjectiveTo describe relationships between tobacco-related environments and disparities in smoking by sexual orientation.MethodsWe examined three aspects of state-level tobacco environments, which were derived from the ImpacTeen State Level Tobacco Control...

Social capital and adolescent smoking: an application of a cross-classified multilevel model

relationship between neighbourhoods and health inequalities, the spatial dimension had tended to be treated as a kind of fixed background that remains external to the social world as well as to efforts to make the world more socially just. However, for certain segments of the population it seems that being in an unhealthy place is not a matter of timing or accident, but rather a function of the social structure. It is also recognised in health promotion that marginalised populations face a double burden: being socially marginalised as individuals and being subject to the inequities resulting from being located in poor environments. This issue will be discussed using the empirical case of the Interdisciplinary Study of Inequalities in Smoking (ISIS) currently underway in Montreal, Canada. ISIS is a cross-lag panel study that uses multi-level linear and nonlinear models to better understand how social inequalities in smoking come about. At the first level of analysis our sample involves 2098 young adults aged 18-25. The second level of analysis is Montreal neighbourhoods. We developed a theoretical framework to guide analyses of the environmental and individual factors implicated in shaping these social inequalities in smoking. Our framework characterises neighbourhoods as unique configurations of five domains (physical, economic, institutional, local sociability and community organizations) through which health-related resources can be accessed. We view this configuration of domains as being shaped and reproduced by the residents’ individual resources, conceptualised as capitals (specifically, economic, cultural, social and biological capitals). This framework and preliminary findings from our first year of data collection will be presented for their relevance to why context matters in health behaviour research.

How important are paper copies of questionnaires? Testing invitations modes when studying social inequalities in smoking among young adults

Using the internet to administer questionnaires for data collection has triggered interest in the past decade of survey research (Israel 2009). In Canada, the general population with access to the internet has grown from 60 % in 2005 to 80 % (Statistics Canada 2011), with young adults following the same trend (Lenhart et al. 2010). However, this trend is not evident across population subgroups as only 54 % of households in the lowest income quartile have access to the internet (Statistics Canada 2011). It is thought that web questionnaire administration can help in countering low response rates and growing research costs, but we were concerned that it should not create socio-economic selection bias problems. Researchers have questioned the influence of invitations that promote access to web versions of questionnaires only, hereby defined as ‘‘Web-only’’ invitations (Kwak and Radler 2002). Indeed, ‘‘Mixed-mode’’ invitations, hereby defined as invitations promoting additional modes of response (paper copy, phone or face-to-face interviews, etc.), have had relative success in increasing response rates (Shih and Fan 2007; Zuidgeest et al. 2011; Van den Berg et al. 2011). With the internet use trends changing rapidly, few recent studies have examined whether response rate and socio-economic status are associated with invitation methods in a population of young adults. In this paper, we report results from a study in which we tested whether adding a paper version of a questionnaire to a mailed invitation (a Mixed-mode invitation) will leads to a sample with different modes of response (i.e. telephone, mail or web), rates of response and socio-demographic characteristics when compared with a Web-only mailed invitation. This study was undertaken within the purview of a larger study entitled the Interdisciplinary Study of Inequalities in Smoking (ISIS), whose goal is to better understand the effects of neighbourhood and individual characteristics in the inequitable socio-economic distribution of smoking across Montreal neighbourhoods.

Using multiple measures of inequalities to study the time trends in social inequalities in smoking

The time trends in social inequalities in smoking have been examined in a number of international publications; however, these studies have rarely used multiple measures of health inequalities simultaneously. Also the analytical approach used often did not account, as recommended, for the changes in the relative distribution of social groups and the changes in the absolute level of the health outcome within social groups. Data from four successive waves of the Belgian Health Interview Survey (1997, 2001, 2004, 2008) were used to study the time trends in educational inequalities in daily smoking for those aged between 15 and 74 years. We estimated two measures of relative inequalities: the OR and the relative index of inequality; and two measures of absolute inequalities: the population attributable fraction and the slope index of inequality. Three of these measures (relative index of inequality, population attributable fraction, slope index of inequality) account for the change in the relative size of the social groups over time. The four measures of inequality were consistent in showing significant inequalities among educational groups. The time trends, however, were less consistent. Measures of trends in relative inequalities witnessed a small linear increase. However, no substantial over time change was observed with the measures of absolute inequalities. The time trends in social inequalities in smoking varied according to the measure of inequality used. This study confirms the importance of using multiple measures of inequalities to understand and monitor social inequalities in smoking.

P1-411 Using multiple measures of social inequalities to study time trends in smoking inequalities

IntroductionTrends in social inequalities in smoking have been examined in a number of international publications; however these studies have rarely used multiple measures of health inequalities and did not compare...

P1-430 Smoking among Brazilian workers: influence of employment status and household context

Despite the overall decline in cigarette smoking prevalence in Brazil in past decades, social inequalities in smoking have persisted and even widened. We investigated the effect of precarious work and...

Tabagismo, situação no mercado de trabalho e gênero: análise da PNAD 2008

This study investigated whether men's and women's work status is associated with current smoking, after adjusting for schooling, income, and health, besides discussing hypotheses for such associations. The sample included individuals 15 to 64 years of age living in metropolitan areas, currently in the work force, and interviewed in the Brazilian National Household Sample Survey (PNAD) in 2008. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were obtained by Poisson regression. After adjusting, smoking prevalence was statistically higher in individuals with informal jobs (men, PR = 1.31, 95%CI: 1.24-1.38; women, PR = 1.22, 95%CI: 1.12-1.31) or who were unemployed (men, PR = 1.31, 95%CI: 1.18-1.44; women, PR = 1.16, 95%CI: 1.03-1.32). Our results confirm that work status is an independent dimension of social inequalities in smoking. The social gradient was steeper in men, but the association between work status and smoking was present in both genders.