Educational inequalities in smoking over the life cycle: an analysis by cohort and gender

The emergence of socioeconomic inequalities in smoking during adolescence and early adulthood

BACKGROUND

While it is known that educational inequalities in smoking start during early and middle adolescence, it is unknown how they further develop until adulthood. The aim of this article is to map, in the Portuguese context, how educational inequalities in smoking emerge from pre-adolescence until young adulthood.

METHODS

This study used longitudinal data from the EPITeen Cohort, which recruited adolescents enrolled in schools in Porto, Portugal. We included the 1,038 participants followed at ages 13 (2003/2004), 17, 21, and 24 years. We computed the odds ratio (OR) for the prevalence of smoking states (never smoking, experimenter, less-than-daily, daily and former smoker) and the incidence of transitions between these states, as function of age and education, stratified by sex. We also added interaction terms between age and education.

RESULTS

Educational inequalities in daily smoking prevalence, with higher prevalence among those with lower educational level, emerged at 17 years old and persisted until higher ages. They were formed in a cumulative way by the increased risk of experimenting between 13 and 17 years, and increased risk of becoming daily smoker between 17 and 21 years. The incidence of smoking cessation was higher among the higher educated. Inequalities were formed similarly for women and men, but with lower level and showed no significance among women.

CONCLUSIONS

These results highlight that actions to prevent smoking should also take in account the potential impact in smoking inequalities, and should focus not only on middle adolescence but also on late adolescence and early adulthood.

Using the Unified Theory of Acceptance and Use of Technology (UTAUT) and e-health literacy(e-HL) to investigate the tobacco control intentions and behaviors of non-smoking college students in China: a cross-sectional investigation

BACKGROUND

Non-smoking college students are starting to smoke in increasing numbers, which shows that their tobacco control situation seems not optimistic. The UTAUT and e-HL are commonly used models and theories to predict health behaviors, while there are few studies on tobacco control. This paper aims to study the influencing factors of tobacco control intention and behavior of non-smoking college students in China by combining the UTAUT and e-HL.

METHODS

Based on the stratified sampling method, 625 college students from 12 universities were selected. Data were collected using a self-made questionnaire designed based on the UTAUT and e-health literacy scales. Data were analyzed by SPSS 22 and AMOS 26, including descriptive statistics, one-way variance analysis and structural equation model analysis.

RESULTS

The results of one-way variance analysis showed that there were significant differences in the score of non-smoking college students' tobacco control intention or behavior by hometowns, monthly living expenses, and parents' smoking history. Performance expectancy, effort expectancy, social influence had direct positive effects on behavioral intention. Facilitating condition, behavioral intention had direct positive impacts on use behavior and e-HL had an indirect positive impact on use behavior.

CONCLUSIONS

The combination of the UTAUT and e-HL can be used as an appropriate framework to predict the influencing factors of non-smoking college students' intention and behavior of tobacco control. Improving performance expectancy, effort expectancy, and e-HL among non-smoking college students, creating positive social environments, and providing facilitating condition are key aspects of increasing their tobacco control intention and behavior. It is also beneficial to promote the implementation of smoke-free campus and smoke-free family projects.

Has the distribution of smoking across young adult transition milestones changed over the past 20 years? Evidence from the 1970 British Cohort Study (1996) and Next Steps (2015-16)

Introduction

Transitions into work and family life during young adulthood exacerbate differences in the progression of smoking over the life-course. Few have considered how changes in smoking and the transition to adulthood in the past two decades have influenced these relationships over time.

Methods

We compared the distribution of smoking at ages 25–26 across transition milestones among 3764 men and 4568 women in the 1970 British Cohort study (1996) and 3426 men and 4281 women in the Next Steps study (2015–16). We regressed occasional and daily smoking status on educational attainment, economic activity, living arrangements, relationship status, and parenthood, adjusting for family background, socio-demographics, and smoking history.

Results

There were few differences in associations between the 1996 and 2015-16 samples. Young men and women were less likely to smoke if they had higher education, were homeowners, and cohabited with a partner. Women were less likely to smoke occasionally if they were full-time students, and men were less likely to smoke daily if they were employed full-time and not living with children. However, comparing associations in 2015–16 to 1996: 1) in men, higher education had a weaker negative association and living with a partner had a stronger negative association with daily smoking; 2) in women, independently renting had a weaker positive association with daily smoking.

Conclusions

Despite considerable changes in smoking and the transition to adulthood over the past two decades, the distribution of smoking at ages 25–26 across transition milestones has been relatively stable during this time period in Great Britain.

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Smoking at ages 25–26 was associated with economic activity, living arrangements, relationship status, and parenthood in 1996 and 2015–16.

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Differences in smoking across transition milestones differed by gender.

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Differences in smoking did not substantially change between 1996 and 2015–16.

The Greek smoking epidemic from a life-course perspective

BACKGROUND

Smoking rates in Greece are the highest recorded among OECD countries, but the historical and life-course evolution of smoking patterns is largely unknown. The present paper addresses this gap.

METHODS

We produce nationally representative life-course trajectories of smoking and related mortality of eight generations of Greek men and women. We estimate the smoking-mortality correlation conditional on several confounders and project the estimates forward.

RESULTS

We show that smoking prevalence among Greek men has plateaued at >60% for all but the youngest generation. For women, smoking prevalence is relatively lower, lags by several generations and follows a hump-shaped pattern. Smoking-attributable mortality is currently peaking for men (nearing 40% of total deaths) and is rising for women. We estimate that it takes ~20 years of smoking to maximize the smoking-mortality correlation (at 0.48 for men and 0.32 for women). Based on this estimation, we forecast that mortality rates will begin falling within the current decade.

CONCLUSIONS

The breadth of the Greek smoking epidemic has been high by international standards, reflecting the ineffective tobacco control efforts in the country. While smoking popularity fell during the Great Recession, policy vigilance is necessary to prevent a relapse once the economy recovers.

"At least someone thinks I'm doing well": a real-world evaluation of the quit-smoking app StopCoach for lower socio-economic status smokers

BACKGROUND

Smoking is more prevalent and persistent among lower socio-economic status (SES) compared with higher-SES groups, and contributes greatly to SES-based health inequities. Few interventions exist that effectively help lower-SES smokers quit. This study evaluated "De StopCoach", a mobile phone delivered eHealth intervention targeted at lower-SES smokers based on the evidence-based StopAdvisor, in a real-world setting (five municipalities) in The Netherlands in 2019-2020.

METHOD

We conducted individual semi-structured interviews with project leaders, healthcare professionals, and participating smokers (N = 22), and examined log data from the app (N = 235). For practical reasons, SES of app users was not measured. Qualitative data were analysed using the Framework Approach, with the Consolidated Framework for Implementation Research (CFIR) and Unified Theory of Acceptance and Use of Technology (UTAUT) as theoretical models.

RESULTS

Qualitative data showed that factors from the Intervention and Setting domains were most important for the implementation. StopCoach seemed suitable for lower-SES smokers in terms of performance and effort expectancy, especially when integrated with regular smoking cessation counseling (SCC). Key barriers to implementation of the app were limited integration of the app in SCC programs in practice, difficulty experienced by project leaders and healthcare professionals to engage the local community, and barriers to SCC more generally (e.g., perceived resistance to quitting in patients) that prevented healthcare professionals from offering the app to smokers. Quantitative data showed that 48% of app users continued using the app after the preparation phase and pre-quit day, and that 33% of app users had attempted to quit. Both app adherence and quit attempts were more likely if smokers also received SCC from a professional coach. Posthoc analyses suggest that adherence is related to higher likelihood of a quit attempt among participants with and without a professional coach.

CONCLUSIONS

Smokers, healthcare professionals and project leaders indicated in the interviews that the StopCoach app would work best when combined with SCC. It also appears from app log that app adherence and quit attempts by app users can be facilitated by combining the app with face-to-face SCC. As such, blended care appears promising for helping individual smokers quit, as it combines the best of regular SCC and eHealth. Further research on blended care for lower-SES smokers is needed.

Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis

Background

Educational disparities in daily smoking begin during adolescence and can lead to educational disparities in health among adults. In particular, vocational students including apprentices have higher daily smoking rates compared to non-vocational students. This study aimed to identify the determinants of the gap in daily smoking between French apprentices and high school students aged 17 in 2008 and in 2017.

Methods

We used data from a cross-sectional repeated survey representative of all French adolescents aged 17 in 2008 and 2017. We conducted a non-linear extension of the Oaxaca-Blinder decomposition technique and included the following variables: sociodemographic and familial characteristics, parental smoking, cannabis and alcohol use, suicidal attempt, grade repetition and money received.

Results

Daily smoking was about two times higher among French apprentices compared to high school students in 2008. This gap did not decrease between 2008 and 2017. Differences in measured characteristics between the two groups explained this gap partly, from 28.6 to 51.2%. Cannabis and alcohol use, money received and parental smoking contributed the most to the daily smoking gap.

Conclusions

Prevention programs could target cannabis and alcohol use as well as parental smoking to help decrease educational disparities in smoking status among French adolescents.

Social distribution of tobacco smoking, alcohol drinking and obesity in the French West Indies

BACKGROUND

Tobacco smoking, alcohol and obesity are important risk factors for a number of non-communicable diseases. The prevalence of these risk factors differ by socioeconomic group in most populations, but this socially stratified distribution may depend on the social and cultural context. Little information on this topic is currently available in the Caribbean. The aim of this study was to describe the distribution of tobacco smoking, alcohol drinking and obesity by several socioeconomic determinants in the French West Indies (FWI).

METHODS

We used data from a cross-sectional health survey conducted in Guadeloupe and Martinique in 2014 in a representative sample of the population aged 15-75 years (n = 4054). All analyses were stratified by gender, and encompassed sample weights, calculated to account for the sampling design and correct for non-response. For each risk factor, we calculated weighted prevalence by income, educational level, occupational class and having hot water at home. Poisson regression models were used to estimate age-adjusted prevalence ratios (PR) and 95% confidence intervals (CI).

RESULTS

Current smoking and harmful chronic alcohol use were more common in men than in women (PR = 1.80, 95% CI = 1.55-2.09; PR = 4.53, 95% CI = 3.38-6.09 respectively). On the other hand, the prevalence of obesity was higher in women than in men (PR = 0.67, 95% CI = 0.57-0.79). Higher education, higher occupational class and higher income were associated with lower prevalence of harmful alcohol drinking in men (PR = 0.43, 95% CI = 0.25-0.72; PR = 0.73, 95% CI = 0.53-1.01; PR = 0.72, 95% CI = 0.51-1.03 respectively), but not in women. For tobacco smoking, no variation by socioeconomic status was observed in men whereas the prevalence of current smoking was higher among women with higher occupational class (PR = 1.47, 95% CI = 1.13-1.91) and higher income (PR = 1.50, 95% CI = 1.11-2.03). In women, a lower prevalence of obesity was associated with a higher income (PR = 0.43, 95% CI = 0.33-0.56), a higher occupational class (PR = 0.63, 95% CI = 0.50-0.80), a higher educational level (PR = 0.36, 95% CI = 0.26-0.50) and having hot water at home (PR = 0.65, 95% CI = 0.54-0.80).

CONCLUSION

Women of high socio-economic status were significantly more likely to be smokers, whereas alcohol drinking in men and obesity in women were inversely associated with socioeconomic status.

Considering the age-graded nature of associations between socioeconomic characteristics and smoking during the transition towards adulthood

Young adulthood is a sensitive period characterized by the accumulation of resources and transitions in and out of education, employment, family, and housing arrangements. The association between these characteristics and smoking outcomes likely varies with age yet few studies address its dynamic age-graded nature. To explore this, we examined 2083 young adults ages 18-25 from the 2011-2012 cross-sectional sample of the Montreal-based Interdisciplinary Study of Inequalities in Smoking. We operationalized participants' socioeconomic characteristics using their resources (e.g., education, income, financial difficulties) and transition stages (i.e., studying, working full-time, living arrangements with parents and children, and being in a relationship). We examined differences in these characteristics' associations with occasional and daily smoking across two-year categories (18-19, 20-21, 22-23, and 24-25) using multinomial logistic regression models with age-based interaction terms. Findings highlighted four characteristics, i.e., educational attainment, personal income, student status, and relationship status, with significant differences in associations with smoking outcomes across age categories. Between the age groups of 18-19 and 24-25: 1) the negative association between low educational attainment and daily smoking increased; 2) the positive association between personal income and daily smoking decreased; 3) the negative association between student status and both outcomes decreased; 4) the negative association between relationship status and occasional smoking increased. Findings support that the associations between young adults' socioeconomic characteristics and smoking outcomes vary substantially during the second and third decades of life. Addressing this has critical implications for identifying vulnerable populations and developing appropriate age-based policies in this age group.

Fumes-tu encore? Quitting among French and American smokers: 2000-2010

PURPOSE

This article examines sociodemographic correlates of initiation and quitting among French and American smokers.

METHODS

National surveys in France and the United States in 2000, 2005, and 2010 were analyzed of ever smokers, 20-75 years old. Bivariate and multivariate logistic regression analyses were conducted on age of initiation and quitting.

RESULTS

Smoking prevalence decreased for Americans each survey year (25.2%, 22.9%, and 17.9%), whereas the comparable figures for the French were 33.9%, 31.5%, and 33.8%. French smokers consumed fewer cigarettes per day (12.9 vs. 14.4 in 2000, 13.5. vs. 16.8 in 2005, and 12.2 vs. 15.1 in 2010), began consuming at a later age, and smoked for a shorter duration. Multiple logistic regression results revealed significant differences in the odds ratios, indicating the relative influence of sociodemographic variables on age of initiation and quitting.

CONCLUSIONS

Quitting smoking continues to be a major challenge, varying by similar factors, particularly education, in both France and the United States.

POLICY IMPLICATIONS

Public policy initiatives to promote quitting must be strengthened, including the need to address population-specific inequalities and disparities in tobacco use and consequences.

Tobacco-attributable burden of cancer according to socioeconomic position in France

Smoking is a major preventable cause of cancers and is increasingly concentrated among the most deprived individuals leading to increasing socioeconomic inequalities in the incidence of cancers linked to smoking. We aimed to estimate the tobacco-attributable cancer burden according to socioeconomic position in France. The analysis was restricted to cancer sites for which tobacco smoking was recognized as a risk factor. Cancer cases by sex, age group and European Deprivation Index (EDI) among people aged 30-74 between 2006 and 2009 were obtained from cancer registries covering ∼20% of the French population. The tobacco-attributable burden of cancer according to EDI was estimated applying the population attributable fraction (PAF) computed with the Peto-Lopez method. The PAF increased from 56% in the least deprived EDI quintile to 70% in the most deprived EDI quintile among men and from 26% to 38% among women. In total, 28% of the excess cancer cases in the four most deprived EDI quintiles in men and 43% in women could be prevented if smoking in these 4 EDI quintiles was similar to that of the least deprived EDI quintile. A substantial smoking-attributable burden of cancer by socioeconomic position was observed in France. The results highlight the need for policies reducing tobacco consumption. More comprehensive interventions integrating the various dimensions of health determinants and proportionate according to socioeconomic position may essentially contribute to the reduction of socioeconomic inequalities in cancer.

Daily and Nondaily Smoking Varies by Acculturation among English-Speaking, US Latino Men and Women

Background

Higher smoking prevalence and quantity (cigarettes per day) has been linked to acculturation in the United States among Latinas, but not Latino men. Our study examines variation between a different and increasingly important target behavior, smoking level (nondaily vs daily) and acculturation by sex.

Methods

An online English-language survey was administered to 786 Latino smokers during July through August 2012. The Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA-II) and other acculturation markers were used. Multinomial logistic regression models were implemented to assess the association between smoking levels (nondaily, light daily, and moderate/heavy daily) with acculturation markers.

Results

Greater ARMSA-II scores (relative risk ratio, RRR=.81, 95% CI: .72-.91) and being born inside the United States (RRR=.42, 95% CI: .24-.74) were associated with lower relative risk of nondaily smoking. Greater Latino orientation (RRR=1.29, 95% CI: 1.11-1.48) and preference for Spanish language (RRR=1.06, 95% CI: 1.02-1.10) and media (RRR=1.12, 95% CI: 1.05-1.20) were associated with higher relative risk of nondaily smoking. The relationship between acculturation and smoking level did not differ by sex.

Conclusion

This study found that among both male and female, English-speaking Latino smokers, nondaily smoking was associated with lower acculturation, while daily smoking was linked with higher acculturation.

A longitudinal study into the reciprocal effects of identities and smoking behaviour: Findings from the ITC Netherlands Survey

OBJECTIVE

Although it has been found that identity constructs related to smoking are associated with changes in smoking behaviour, the direction of causal associations is as yet unclear. This study aims to clarify the nature and direction of these associations.

METHODS

In this longitudinal study we examined the reciprocal relations between identity constructs (i.e., smoker self-identity, quitter self-identity and smoker group-identity), intention to quit and smoking and quitting behaviour among a sample of 1036 smokers and ex-smokers, using cross-lagged structural equation modelling. Moreover, we tested whether these relations differed by socio-economic status (SES).

RESULTS

Identity and smoking behaviour were reciprocally related in that in intention to quit and smoking behaviour consistently predicted identity change, and identity predicted (changes in) intentions to quit and smoking behaviour. Behaviour appears more important for identity change than identity for behaviour change. Furthermore, quitter self-identity appears more important than smoker self- and group-identity. Relationships did not differ significantly between SES-groups. The findings were replicated using a cross-validation sample.

CONCLUSION

Results imply that changing smoking behaviour may be a vehicle to change smoking-related identity. Moreover, strengthening identification with quitting is more crucial for quit success than decreasing smoker identities. The finding that behaviour may be more important for identity than vice versa, if replicated, may call for additions to identity theories.

Occupational prestige trajectory and the risk of lung and head and neck cancer among men and women in France

OBJECTIVES

This study aimed at investigating the associations between occupational prestige trajectories and lung and head and neck (HN) cancer risk and to assess to what extent smoking, alcohol drinking, and occupational exposures contribute to these associations.

METHODS

Using data from the ICARE case-control study (controls (2676 men/715 women), lung cancers (2019 men/558 women), HN cancers (1793 men/305 women), we defined occupational prestige trajectories using group-based modeling of longitudinal data. We conducted logistic regression models.

RESULTS

Among men, a gradient was observed from the downward "low to very low" trajectory to the stable very high trajectory. The associations were reduced when adjusting for tobacco and alcohol consumption and occupational exposures. Among women, when compared to the stable high trajectory, there was an increased cancer risk in all trajectories. The associations remained globally unchanged or even increased after adjustment for tobacco and alcohol consumption and did not change when adjusting for occupational exposures. The ORs were smaller for lung than for HN cancers in men.

CONCLUSIONS

Occupational prestige trajectory is strongly associated with lung and HN cancer risk in men and women.

Do social characteristics influence smoking uptake and cessation during young adulthood?

OBJECTIVES

This study uses a Bourdieusian approach to assess young adults' resources and examines their association with smoking initiation and cessation.

METHODS

Data were drawn from 1450 young adults participating in the Interdisciplinary Study of Inequalities in Smoking, a cohort study in Montreal, Canada. We used logistic regression models to examine the association between young adults' income, education, and peer smoking at baseline and smoking onset and cessation.

RESULTS

Young adults where most or all of their friends smoked had greater odds of smoking onset. Young adults that had completed pre-university postsecondary education also had higher odds of smoking onset after controlling for social support, employment status, and lacking money to pay for expenses. Income and the sociodemographic variables age and sex were not associated with smoking onset. Young adults where half of their friends smoked or where most to all of their friends smoked had lowers odds of smoking cessation. Men were more likely to cease smoking than women. Education, income and age were not associated with cessation.

CONCLUSIONS

Interventions focusing on peer smoking may present promising avenues for tobacco prevention in young adults.

Changes in Smoking Behavior over Family Transitions: Evidence for Anticipation and Adaptation Effects

The study of changes in smoking behaviors over the life course is a promising line of research. This paper aims to analyze the temporal relation between family transitions (partnership formation, first childbirth, separation) and changes in smoking initiation and cessation. We propose a discrete-time logistic model to explore the timing of changes in terms of leads and lags effects up to three years around the event in order to measure both anticipation and adaptation mechanisms. Retrospective biographical data from the Santé et Itinéraires Professionnels (SIP) survey conducted in France in 2006 are used. Partnership formation was followed for both genders by a fall in smoking initiation and an immediate rise in smoking cessation. Childbirth was associated with increased smoking cessation immediately around childbirth, and additionally, females showed an anticipatory increase in smoking cessation up to two years before childbirth. Couple separation was accompanied by an anticipatory increase in smoking initiation for females up to two years prior to the separation, but this effect only occurred in males during separation. Our findings highlight opportunities for more targeted interventions over the life course to reduce smoking, and therefore have relevance for general practitioners and public policy elaboration.

Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States

Widening of educational disparities and a narrowing female advantage in mortality stem in good part from disparities in smoking. The changes in smoking and mortality disparities across cohorts and countries have been explained by an epidemic model of cigarette use but are also related to life course changes. To better describe and understand changing disparities over the life course, we compare age patterns of smoking in three cohorts and two nations (France and the United States) using smoking history measures from the 2010 French Health Barometer (N = 20,940) and the 2010 U.S. National Health Interview Survey Sample Adult File (N = 20,444). The results demonstrate statistically significant widening of gender and educational differences from adolescence to early and middle adulthood, thus accentuating the disparities already emerging during adolescence. In addition, the widening disparities over the life course have been changing across cohorts: Age differences in educational disparities have grown in recent cohorts (especially in France), while age differences in gender disparities have narrowed. The findings highlight the multiple sources of inequality in smoking and health in high-income nations.

Quantifying the mediating effects of smoking and occupational exposures in the relation between education and lung cancer: the ICARE study

Smoking only partly explains the higher lung cancer incidence observed among socially deprived people. Occupational exposures may account for part of these inequalities, but this issue has been little investigated. We investigated the extent to which smoking and occupational exposures to asbestos, silica and diesel motor exhaust mediated the association between education and lung cancer incidence in men. We analyzed data from a large French population-based case-control study (1976 lung cancers, 2648 controls). Detailed information on lifelong tobacco consumption and occupational exposures to various carcinogens was collected. We conducted inverse probability-weighted marginal structural models. A strong association was observed between education and lung cancer. The indirect effect through smoking varied by educational level, with the strongest indirect effect observed for those with the lowest education (OR = 1.34 (1.14-1.57)). The indirect effect through occupational exposures was substantial among men with primary (OR = 1.22 (1.15-1.30) for asbestos and silica) or vocational secondary education (OR = 1.18 (1.12-1.25)). The contribution of smoking to educational differences in lung cancer incidence ranged from 22 % (10-34) for men with primary education to 31 % (-3 to 84) for men with a high school degree. The contribution of occupational exposures to asbestos and silica ranged from 15 % (10-20) for men with a high school degree to 20 % (13-28) for men with vocational secondary education. Our results highlight the urgent need for public health policies that aim at decreasing exposure to carcinogens at work, in addition to tobacco control policies, if we want to reduce socioeconomic inequalities in the cancer field.

A Novel Indicator of Life-Course Smoking Prevalence in the United States Combining Popularity, Duration, Quantity, and Quality of Smoking

OBJECTIVES

To develop a smoking indicator that combines the popularity and duration of smoking and the quantity and quality of consumed cigarettes, factors that vary dramatically over time and across generations.

METHODS

We used retrospective reports on smoking behavior and a time series of cigarette tar yields to standardize nationally representative life-course smoking prevalence rates of 11 generations of US men and women, spanning 120 years. For each generation and gender, we related the standardized data with the corresponding rates of smoking-attributable mortality.

RESULTS

Our indicator suggests that US cigarette consumption spread, peaked, and contracted faster than commonly perceived; predicts a significantly stronger smoking-mortality correlation than unadjusted smoking prevalence; and reveals the emergence of a delay (by up to 8 years) in premature death from smoking that is consistent with increasing population access to effective treatments. In fact, we show that, among recent cohorts, smoking health-risk exposure is at a historic low and will account for less than 5% of deaths.

CONCLUSIONS

Relative to unstandardized measures, our novel, standardized indicator of smoking prevalence describes a different history of smoking diffusion in the United States, and more strongly predicts later-life mortality.