Area-level characteristics and smoking in women

Neighbourhood and individual socioeconomic inequalities in smoking: the role of physical neighbourhood stressors

OBJECTIVE

To explore the association between physical neighbourhood stressors and smoking, and the contribution of these stressors to neighbourhood and individual socioeconomic inequalities in smoking.

METHODS

Data were analysed of participants of the baseline measurement of the Dutch GLOBE study (1991), aged 20 years and older, who lived in 79 neighbourhoods of the city of Eindhoven (n = 9062). The neighbourhood socioeconomic environment was assessed from aggregated self reported information of participants' education and occupation level, and employment status. Neighbourhood stressors included were the physical quality (decay), required police attention, noise pollution from traffic, and population density in neighbourhoods. Current smokers were distinguished from previous and never smokers.

RESULTS

Compared with those living in the most advantaged neighbourhoods, residents living in the socioeconomically most disadvantaged neighbourhoods were more likely to smoke (adjusted for age, sex, education, occupation, and employment status) (OR = 1.24, 95% CI 1.05 to 1.46). An increase in a summary neighbourhood stressor score was associated with smoking, independently of the neighbourhood socioeconomic environment (OR = 1.57, 95% CI 1.11 to 2.21, in the neighbourhoods with the highest stress score). Adjustment for the score substantially reduced the odds ratio for living in the socioeconomic most disadvantaged neighbourhoods (OR = 1.03, 95% CI 0.84 to 1.28, for those in the most disadvantaged neighbourhoods). Neighbourhood stressors contributed 10% to the increased probability of smoking in the lowest educated persons.

CONCLUSIONS

Physical neighbourhood stressors are related to smoking and contribute substantially to neighbourhood inequalities in smoking over and above individual level characteristics.

Individual, neighborhood, and state-level predictors of smoking among US Black women: a multilevel analysis

Baseline data from the Black Women's Health Study (BWHS) were analyzed to assess the relation of smoking to individual, neighborhood, and state socioeconomic characteristics. Data on smoking status and individual socioeconomic characteristics were obtained via a self-administered postal questionnaire at entry. Neighborhood characteristics of 41,726 never and current smokers were obtained by linking participants' addresses with census tract data from the 1990 US Census. In a multilevel logistic regression model, higher neighborhood poverty was associated with increased smoking prevalence after adjusting for age, education, marital status, and occupation at the individual level, and percent high school graduate, percent college graduate, and percentage Black at the neighborhood level. Relative to women residing in neighborhoods with less than 5% of the residents below the poverty line, the odds ratio was 1.1 (95% confidence interval: 1.0-1.2) for women in neighborhoods with 5-9.9% of the residents below the poverty line, 1.3 (1.2-1.4) for women in neighborhoods with 10-19.9% of the residents below the poverty line, and 1.6 (1.5-1.8) for women in neighborhoods with 20% or more of the residents below poverty. State of residence was also significantly associated with prevalence of current smoking. These results suggest that contextual factors (at both the neighborhood and state level) play a role in Black women's smoking behaviors over and above individual characteristics.

Prevalence and correlates of tobacco use among Russian cancer patients: Implications for the development of smoking cessation interventions at a cancer center in Russia

This study examined the rate of smoking among 399 cancer patients in Russia and assessed correlates of tobacco use and readiness to quit smoking. The results indicated that (a) 41.6% of patients were smokers; and (b) smokers were likely to be male, have lung or colorectal cancer, exhibit low levels of knowledge concerning the negative effects of smoking, report a low level of advantages to quitting smoking and a high level of disadvantages to quitting smoking, show low perceived risk for the adverse effects of smoking, and exhibit high fatalistic beliefs. Though certain findings converge well with data collected from U.S. samples of cancer patients, these results can guide the development of smoking interventions that address the specific needs of Russian cancer patients. In sum, this study fills a critical gap in knowledge concerning the epidemic of tobacco use in Russia and broadens research regarding tobacco use by cancer patients from the United States to the Russian Federation.

Polymorphisms in nucleotide excision repair genes, smoking and breast cancer in African Americans and whites: a population-based case-control study

Polymorphisms exist in several genes involved in nucleotide excision repair (NER), the principal pathway for removal of smoking-induced DNA damage. An epidemiologic study was conducted to determine whether these polymorphisms modify the association between smoking and breast cancer. DNA samples and exposure histories were analyzed as part of a large population-based case-control study of breast cancer in North Carolina. The study population included 2311 cases (894 African Americans, 1417 whites) and 2022 controls (788 African Americans, 1234 whites). Odds ratios (ORs) were calculated for breast cancer and smoking, and for breast cancer and nine non-synonymous coding polymorphisms in six NER genes (XPD codons 312 and 751, RAD23B codon 249, XPG codon 1104, XPC codon 939, XPF codons 415 and 662, and ERCC6 codons 1213 and 1230). Modification of ORs for smoking by single and combined NER genotypes was investigated. In this study population, smoking was more strongly associated with breast cancer in African American women compared with white women. Among African American women, the association of breast cancer and smoking was strongest among women with specific combinations of NER genotypes. Evidence for multiplicative interaction was found between combined NER genotypes and smoking dose (likelihood ratio test P = 0.06), duration (P = 0.09), time since cessation (P = 0.02), age at initiation (P = 0.04) and former smoking (P = 0.03). No interactions were observed in white women. Therefore, polymorphisms in NER genes may modify the relationship between breast cancer and smoking. These results are consistent with previous evidence of exposure-specific p53 mutations in breast tumors from current and former smokers, suggesting that smoking may play a role in breast cancer etiology.

Effects of neighbourhood socioeconomic status and convenience store concentration on individual level smoking

OBJECTIVES

To assess the effects of neighbourhood level socioeconomic status (SES) and convenience store concentration on individual level smoking, after consideration of individual level characteristics.

DESIGN

Individual sociodemographic characteristics and smoking were obtained from five cross sectional surveys (1979-1990). Participants' addresses were geocoded and linked with census data for measuring neighbourhood SES and with telephone yellow page listings for measuring convenience store concentration (density in a neighbourhood, distance between a participant's home and the nearest convenience store, and number of convenience stores within a one mile radius of a participant's home). The data were analysed with multilevel Poisson regression models.

SETTING

82 neighbourhoods in four northern California cities.

PARTICIPANTS

8121 women and men aged 25-74 from the Stanford heart disease prevention programme.

MAIN RESULTS

Lower neighbourhood SES and higher convenience store concentration, measured by density and distance, were both significantly associated with higher level of individual smoking after taking individual characteristics into account. The association between convenience store density and individual smoking was modified by individual SES and neighbourhood SES.

CONCLUSIONS

These findings are consistent with a growing body of literature suggesting that the socioeconomic and physical environments of neighbourhoods are associated with individual level smoking.

The usefulness of area-based socioeconomic measures to monitor social inequalities in health in Southern Europe

BACKGROUND

The study objective was to investigate the association between health outcomes and several small-area-based socioeconomic measures and also with individual socioeconomic measures as a check on external validity.

METHODS

Cross-sectional design based on the analysis of the Barcelona Health Interview Survey of 1992. A representative stratified sample of the non-institutionalised population resident in Barcelona city (Spain) was obtained. The present study refers to the 4171 respondents aged over 14. We studied perceived health status, presence of chronic conditions and smoking as health outcomes. Area socioeconomic measures (1991 census) were generated at census tract level and individual socioeconomic measures were educational level and social class obtained through the survey.

RESULTS

With individual socioeconomic measures we observed that the lower the educational level or social class, the higher the probability of reporting a perceived health status of fair, poor or very poor and of presenting some chronic condition. With regard to smoking, among men this trend was similar [odds ratio (OR) = 1.5; 95% confidence interval (CI) = 1.2-1.9 in social classes IV-V with respect to social classes I-II], while among women it was reversed (OR = 0.7; 95% CI = 0.5-0.9). With the different area-based socioeconomic indicators differences were also observed in this sense, with the exception of smoking in women for which these indicators do not show any differences by socioeconomic level.

CONCLUSIONS

With several census area-based socioeconomic measures similar effects on inequalities in health have been observed. In general, these inequalities were in the same sense as those obtained with individual-based measures. Small-area-based socioeconomic measures from the Spanish census could greatly enhance analysis of social inequalities in health, overcoming the absence of socioeconomic data in public health registries and in medical records.

Socioeconomic pattern of smoking in Japan: income inequality and gender and age differences

PURPOSE

To elucidate the influence of individual socioeconomic status on smoking in Japanese adults.

METHODS

Using a nationally representative sample (20,206 men and 21,093 women aged 18 to 54 years), the relation between smoking and socioeconomic characteristics was analyzed by sex and age group (18 to 24, 25 to 39, and over 40 years).

RESULTS

The smoking prevalence was 57.0% for men and 16.6% for women. Living in an urban area was a negative factor for smoking in men, while a positive factor in women. Being married was positively associated with smoking in the younger population, but negatively associated in the older population. A relation between lower income and smoking was found in all groups, except in men aged 18 to 24 years. The income-related difference was most pronounced in the population aged 25 to 39 years: OR of smoking for the highest income quintile compared with the lowest was 0.60 (95% CI, 0.51-0.71) for men and 0.29 (95% CI, 0.23-0.35) for women.

CONCLUSIONS

Socioeconomic status, especially income, substantially predicted smoking in the Japanese population, while the impact differed according to sex and age groups. Effective anti-smoking strategies require consideration of the gender and age differences in the socioeconomic pattern of smoking.

Challenges in understanding disparities in drug use and its consequences

Racial/ethnic disparities in health have long been documented in a broad range of medical conditions in the United States. For example, Blacks have higher HIV incidence and AIDS-related mortality than do Whites. This article summarizes racial/ethnic differences in drug use and its consequences in the United States and proposes three key challenges to the study of disparities in drug use and its consequences. These are (a) patterns of drug use and misuse are complex, with different patterns of use of different drugs in different racial/ethnic groups; (b) racial/ethnic differences in use of drugs are not always associated with comparable differences in the consequences of drug use; and (c) the consequences of drug use are associated with drug use itself and other social/economic circumstances. Each of these challenges is discussed, and suggestions offered for future research that may help overcome them.

Active and passive smoking and breast cancer risk in middle‐aged Japanese women

To examine the hypothesis that tobacco smoke is associated with the risk of female breast cancer, we estimated the relative risks of active and passive smoke in middle-aged Japanese women in a population-based prospective study. The cohort consisted of residents in 4 public health center areas, aged 40 to 59 years. A self-administered questionnaire survey was conducted in 1990. This analysis included 21,805 subjects, 180 of whom had developed breast cancer by December 31, 1999. When the reference was defined as never-active smokers without passive smoking, adjusted relative risks (RRs) were 1.9 (95% confidence interval [CI] = 1.0-3.6) in current active smokers, 1.2 (95% CI = 0.4-4.0) in ex-active smokers and 1.2 (95% CI = 0.8-1.6) in never-active smokers with passive smoking. The elevated risk for ever-smokers was clearly observed in premenopausal women at baseline (RR = 3.9, 95% CI = 1.5-9.9) but not in postmenopausal women (RR = 1.1, 95% CI = 0.5-2.5). In never-active smokers, the adjusted RR for passive smoking, residential or occupational/public tobacco smoke exposure was 1.1 (95% CI = 0.8-1.6). In premenopausal women, passive smoking increased the risk (RR = 2.6; 95% CI = 1.3-5.2) but not in postmenopausal women (RR = 0.7; 95% CI = 0.4-1.0). We conclude that tobacco smoking increases the risk of female breast cancer in premenopausal women.

Associations of smoking prevalence with individual and area level social cohesion

STUDY OBJECTIVE

To discover if area level social cohesion, neighbourhood safety, and home safety are associated with current cigarette smoking among adults after adjustment for concentrations of poverty and low education.

DESIGN

Cross sectional survey of a random sample of adults, stratified by 19 geographical areas.

SETTING

SHAPE, Survey of the Health of Adults, the Population, and the Environment-conducted in 1998 by the Hennepin County Community Health Department and the Minneapolis Department of Health and Family Support in Minnesota.

PARTICIPANTS

5256 men and 4806 women, 18 years and older, randomly selected from 19 geographical areas in an urban county.

MAIN RESULTS

Overall, 21.2% of survey respondents reported current cigarette smoking. Both higher area level social cohesion (OR = 0.85, 95% CI = 0.74 to 0.98) and higher individual social cohesion (OR = 0.96, 95% CI = 0.92 to 0.99) were associated with lower likelihoods of smoking. Similar models were obtained for neighbourhood safety and home safety.

CONCLUSIONS

These findings contribute to the growing literature on the important role of social cohesion and other area level characteristics on smoking behaviour among adults.

A multilevel analysis of tobacco use and tobacco consumption levels in France: are there any combination risk groups?

BACKGROUND

Both the predictors for tobacco use and the determinants of the amounts of tobacco consumed by smokers should be taken into account when designing prevention programmes.

METHODS

Using a sample of 12,948 individuals representative of the French population in 1999, multilevel models were used to carry out a comparative investigation for the predictors of tobacco use and the determinants of the amount of tobacco consumed by smokers.

RESULTS

At the individual level, a combination of risks (higher risk of smoking and larger amounts of tobacco consumed by smokers) was found for males, for individuals with a low level of education and for divorcees. At the level of the area of residence, both the risk of smoking (odds ratio 1.07, 95% confidence interval: 1.01-1.12 for an increase by one standard deviation) and the amount of tobacco consumed among smokers (percentage variation +4%, 95% confidence interval: 0% - +8%) increased with the gross domestic product per capita.

CONCLUSION

This study justifies the combined use, in such analyses, of consumption levels for smokers in addition to the risk of smoking, in order to identify the profiles with the highest risk. It was possible to identify various groups with both a high risk of tobacco use and a high level of consumption among smokers, on the basis of individual (male, divorced or less educated) and environmental (living in a high GDP area) factors. The prevention efforts should thus be focused on such groups.

Smoking urges and relapse among lung cancer patients: findings from a preliminary retrospective study

BACKGROUND

As part of a prospective study of relapse to smoking among previously resected lung cancer patients, we conducted a retrospective survey to examine factors that may contribute to relapse.

METHODS

Patients who had smoked within 3 months before surgery completed measures assessing demographic characteristics, smoking urges, depression, social support, and psychological reactance.

RESULTS

Of 43 participants, 19 had relapsed at some point since surgery and 13 were currently smoking. Patients were at relatively low risk of relapse immediately following hospitalization, but at greater risk beginning 2 months later. Younger age and lower educational level predicted current smoking and shorter time to relapse. Craving to smoke was measured as: Appetitive urge (anticipation of pleasure) and Aversive urge (avoidance of negative affect). Both were greater among current smokers. Aversive urge was significantly correlated with depression. Those high on both psychological reactance and Directive social support had heightened Appetitive urges.

CONCLUSION

Among lung cancer patients, relapse to smoking may be delayed several months but remains a problem. Appetitive and Aversive motivational pathways and associated urges appear useful in organizing study of the role of psychosocial factors such as depression and social support in relapse to smoking in this group.

Social participation, social capital and daily tobacco smoking: a population-based multilevel analysis in Malmö, Sweden

AIMS

The aim of this study was to investigate the influence of contextual and individual factors on daily tobacco smoking.

METHODS

The public-health survey in Malmö 1994 is a cross-sectional study. A total of 5600 individuals aged 20-80 years were invited to answer a postal questionnaire. The participation rate was 71%. A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second, was performed. We analysed the effect (intra-area correlation, cross-level modification and odds ratios) of individual and neighbourhood factors on smoking after adjustment for individual factors.

RESULTS

Neighbourhood factors accounted for 2.5% of the crude total variance in daily tobacco smoking. This effect was significantly reduced when the individual factors such as education were included in the model. However, individual social capital, measured by social participation, only marginally affected the total neighbourhood variance in daily tobacco smoking. In fact, no significant variance in daily tobacco smoking remained after the introduction of the individual factors other than individual social capital in the model.

CONCLUSION

In Malmö, the neighbourhood variance in daily tobacco smoking is mainly affected by individual factors other than individual social capital, especially socioeconomic status measured as level of education.

Context and beliefs about smoking and smoking cessation

PURPOSE

To describe the context of, and beliefs about, smoking cessation in a sample of low-income African American pregnant women.

STUDY DESIGN & METHODS

A naturalistic descriptive qualitative approach was used with 15 women. Face-to-face interviews were conducted using a semi-structured interview guide. Interviews were transcribed verbatim and a thematic content analysis conducted. Perinatal health complication data were extracted from the participants' medical records and summarized.

RESULTS

Two major themes were identified. The context of smoking cessation theme was Living the Stressful Life, with subthemes of Personal and Community Stress, Personal Health Problems, and Smoking For Stress Management. The second major theme was Personal Accountability for Smoking Cessation. There was a mismatch between women's sources of stress (which were out of their control) and their perceived locus of change (which was personal behavior).

CLINICAL IMPLICATIONS

To improve the outcomes of tobacco control programs for low-income women, we need to take action to create healthier communities.

Residential area deprivation predicts smoking habit independently of individual educational level and occupational social class. A cross sectional study in the Norfolk cohort of the European Investigation into Cancer (EPIC-Norfolk)

OBJECTIVES

To investigate the independent association between individual and area based measures of socioeconomic status and cigarette smoking habit.

DESIGN AND SETTING

Cross sectional, population based study.

PARTICIPANTS AND METHODS

12 579 men and 15 132 women aged 39-79 years living in the general community participating in the EPIC-Norfolk Study in 1993-1997. The association between social class, educational status, Townsend residential deprivation level, and cigarette smoking status was examined.

MAIN OUTCOME MEASURES

Cigarette smoking status at baseline survey.

RESULTS

Social class, educational level, and residential deprivation level independently related to cigarette smoking habit in both men and women. Multivariate age adjusted odds ratios for current smoking in men were 1.62 (95% CI 1.45 to 1.81) for manual compared with non-manual social class, 1.32 (95% CI 1.17 to 1.48) for those with educational level less than O level compared with those with O level qualifications or higher and 1.84 (95% CI 1.62 to 2.08) for high versus low area deprivation level. For women, the odds ratios for current smoking for manual social class were 1.14 (95% CI 1.03 to 1.27); 1.31 (95% CI 1.18 to 1.46) for low educational level and 1.68 (95% CI 1.49 to 1.90) for high residential deprivation respectively.

CONCLUSIONS

Residential deprivation level using the Townsend score, individual social class, and educational level all independently predict smoking habit in both men and women. Efforts to reduce cigarette smoking need to tackle not just individual but also area based factors. Understanding the specific factors in deprived areas that influence smoking habit may help inform preventive efforts.

Voucher-based incentives. A substance abuse treatment innovation

In this report we provide an overview of research on the voucher-based incentives approach to substance abuse treatment. This approach was originally developed as a novel method for improving retention and increasing cocaine abstinence among cocaine-dependent outpatients. The efficacy of vouchers for those purposes is now well established, and plans are underway to move the intervention into effectiveness testing in community clinics. The use of vouchers also has been extended to the treatment of alcohol, marijuana, nicotine, and opioid dependence. Particularly noteworthy is that vouchers hold promise as an efficacious intervention with special populations of substance abusers, including pregnant and recently postpartum women, adolescents, and those with serious mental illness. Overall, voucher-based incentives hold promise as an innovative treatment intervention that has efficacy across a wide range of substance abuse problems and populations.