Social network and inequalities in smoking amongst school-aged adolescents in six European countries

Socio-economic inequalities in smoking and drinking in adolescence: Assessment of social network dynamics

AIMS

We investigated whether (1) adolescents selected friends with a similar socio-economic status (SES), (2) smoking and alcohol consumption spread in networks and (3) the exclusion of non-smokers or non-drinkers differed between SES groups.

DESIGN

This was a longitudinal study using stochastic actor-oriented models to analyze complete social network data over three waves.

SETTING

Eight Hungarian secondary schools with socio-economically diverse classes took part.

PARTICIPANTS

This study comprised 232 adolescents aged between 14 and 15 years in the first wave.

MEASUREMENTS

Self-reported smoking behavior, alcohol consumption behavior and friendship ties were measured. SES was measured based upon entitlement to an income-tested regular child protection benefit.

FINDINGS

Non-low-SES adolescents were most likely to form friendships with peers from their own SES group [odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.02-1.11]. Adolescents adjusted their smoking behavior (OR = 24.05, 95% CI = 1.27-454.86) but not their alcohol consumption (OR = 1.65, 95% CI = 0.62-4.39) to follow the behavior of their friends. Smokers did not differ from non-smokers in the likelihood of receiving a friendship nomination (OR = 0.98, 95% CI = 0.87-1.10), regardless of their SES. Alcohol consumers received significantly more friendship nominations than non-consumers (OR = 1.16, 95% CI = 1.01-1.33), but this association was not significantly different according to SES.

CONCLUSIONS

Hungarian adolescents appear to prefer friendships within their own socio-economic status group, and smoking and alcohol consumption spread within those friendship networks. Socio-economic groups do not differ in the extent to which they encourage smoking or alcohol consumption.

Smoking prevention within social work organizations: a qualitative study about youngsters' and youth workers' perceptions

Tobacco smoking uptake is still a major public health concern, especially among youngsters living in vulnerable situations. Finding optimal ways to engage youngsters in smoking prevention is important. Compared to traditional settings such as schools, social work settings providing sports-based and recreational activities (SR-settings) tend to reach and engage youngsters more. This study aimed to gain insight into the reasons for smoking uptake among youngsters living in vulnerable situations and the conditions through which SR-settings are potentially beneficial for smoking prevention initiatives. Data were collected in two SR-settings in Flanders, Belgium, by means of five focus group discussions and six individual interviews with youngsters (n = 38, mean age = 12.9 ± 2.61 years, 69.7% boys) and eight individual interviews with youth workers (n = 8, mean age = 27.5 ± 7.95 years, 87.5% men). A thematic analysis (TA) approach was applied to analyse the data. Besides individual factors, such as attitudes towards smoking, the desire to be part of a group and conformity to group norms seem to be important drivers of smoking uptake among youngsters in vulnerable situations. The presence of powerful role models in SR-settings with whom youngsters identify may counteract group norms by encouraging healthy behaviour. SR-settings seem suitable for questioning perceptions of vulnerable youngsters, unlike other settings where they may struggle to be heard. The conditional characteristics of SR-settings, such as authentic group processes, having meaningful roles, and being heard, make these contexts promising venues for smoking prevention efforts among vulnerable youngsters. Youth workers who have established trusting relationships with youngsters seem well-suited to communicate smoking prevention messages. A participatory approach, in which youngsters are involved in developing smoking prevention programs, is desirable.

Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial

BACKGROUND

Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking.

METHODS

A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation.

RESULTS

Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention.

CONCLUSION

This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved.

TRIAL REGISTRATION

https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.

The Diffusion of Smoking: Association Between School Tobacco Policies and the Diffusion of Adolescent Smoking in 38 Schools in 6 Countries

Social network research has evidenced the role of peer effects in the adoption of behaviours. Little is known, however, about whether policies affect how behaviours are shared in a network. To contribute to this literature, we apply the concept of diffusion centrality to school tobacco policies and adolescent smoking. Diffusion centrality is a measure of centrality which refers to a person's ability to diffuse a given property-in our case, smoking-related behaviours. We hypothesized that stronger school tobacco policies are associated with less diffusion centrality of smoking on school premises and of smoking in general. A whole network study was carried out in 2013 and 2016 among adolescents (n = 18,805) in 38 schools located in six European cities. Overall, diffusion centrality of smoking in general and of smoking on school premises significantly decreased over time. Diffusion centrality of smoking significantly decreased both in schools where the policy strengthened or softened over time, but for diffusion of smoking on school premises, this decrease was only significant in schools where it strengthened. Finally, stronger school tobacco policies were associated with lower diffusion centrality of smoking on school premises and of smoking in general, though to a lesser extent. With such policies, smoking may, therefore, become less prevalent, less popular, and less clustered, thereby lowering the risk of it spreading within networks in, and even outside the school.

Social network analysis to study health behaviours in adolescents: A systematic review of methods

PURPOSE

Our objectives were (i) to systematically review how SNA is used in studies investigating adolescent health behaviours (i.e., the purpose of using SNA, methods used for network data collection and analysis), and (ii) to develop methodological guidelines to help researchers use SNA in studies on adolescent health behaviours.

METHODS

Five databases were searched using keywords related to "social network analysis" and "adolescents". We extracted data from included articles pertaining to the choice of methods for network data collection and analysis. We used these data to develop a 5-step decision tree to help researchers make methodological decisions most appropriate to their research objectives.

RESULTS

A total of 201 articles were included. Most investigated tobacco (50%) or alcohol use (48%). SNA was used most often to examine processes related to peer selection or influence (37%) and/or to examine the effect of sociometric position on health behaviours (34%). 181 studies (90%) used a sociocentric approach for SNA, 16 studies (8%) used an egocentric approach, and 4 studies (2%) used both. We identified five decision-making steps in SNA including the choice of: (i) network boundary, (ii) SNA approach, (iii) methods for name generators, (iv) methods for name interpreters, and (iv) SNA indicators.

CONCLUSION

This study provides insights and guidance in a 5-step decision tree on practical and methodological considerations in using SNA to explore adolescent health behaviours.

Predictors of smoking initiation among Thai adolescents from low-income backgrounds: A case study of Nakhon Pathom low-cost housing estates

INTRODUCTION

Globally, an estimated 1.3 billion people in the world smoke tobacco products, of which more than 8 million die annually. A disproportionate number of these deaths occur in low- and middle-income countries like Thailand. Over 19% (10.7 million) of the Thai population aged ≥15 years were estimated to be smokers; of these, 7.8% were aged 15–18 years. Nearly 1 in 10 Thai students is a current tobacco user; about 20% of these smokers had initiated smoking before their 10th birthday. This shows that early smoking initiation among Thai youths is indeed a public health problem. This study was conducted to examine the factors associated with smoking initiation among adolescents from low-income backgrounds.

METHODS

A cross-sectional study was conducted among youth aged 15–18 years living in low-cost housing estates in Nakhon Pathom province between 1 December 2019 and 30 July 2020. A total of 290 participants were recruited by stratified random sampling. A proprietary questionnaire was used to collect the data, which were analyzed by binary logistic regression.

RESULTS

Risk factors for smoking initiation were having one or both parents deceased (OR=2.28; 95% CI: 1.218–3.471, p=0.001), having divorced parents (OR=1.67; 95% CI: 1.158–2.509, p=0.013), and poor academic performance (OR=2.50; 95% CI: 0.133–3.551, p=0.032). Protective factors were having knowledge of cigarettes (OR=0.65; 95% CI: 0.179–0.895, p=0.004) and correct perception of legal public smoking places (OR=0.45; 95% CI: 0.140–0.850, p=0.025).

CONCLUSIONS

To curb the risks of early smoking initiation among youths of low-income backgrounds, both education and health authorities need to collaboratively design interventions tailored to raise awareness of the negative health impacts of tobacco, improve the performance of underperforming students, and meet the social needs of students whose parents are either deceased or separated to improve their social ties.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review

BACKGROUND

Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions.

METHODS

The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position.

RESULTS

Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after.

CONCLUSIONS

Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Severe Social Anxiety Among Adolescents During COVID-19 Lockdown

To study the prevalence of severe social anxiety (SSA) among a group of adolescents during the coronavirus disease of 2019 (COVID-19) pandemic. A total of 178 adolescents attending the private clinics of the authors were screened online for the presence of SSA, by using the self-reporting format of the Liebowitz Social Anxiety Scale for children and adolescents (LSAS-CA). SSA defined as LSAS-CA scores of 80 or more was checked for statistical association with the adolescents' sociodemographic data and knowledge about the COVID-19 infection. The 18% of our participants had SSA, no correlation was found between having SSA and ä acknowledging or fearing the COVID-19 morbidity. Factors associated with SSA included texting, using social media, and playing video games during the lockdown. Mitigating factors include high family socioeconomic status, history of socialization with friends, and the use of WhatsApp as a source of information about COVID-19 infection.

Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating¹ a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)]², a course for school staff in short motivational conversations³, school class-based teaching material⁴, an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students' acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

The association between socioeconomic position and vigorous physical activity among adolescents: a cross-sectional study in six European cities

Background

The relationship between socioeconomic position (SEP) and adolescent physical activity is uncertain, as most evidence is limited to specific settings and a restricted number of SEP indicators. This study aimed to assess the magnitude of socioeconomic differences in adolescent vigorous physical activity (VPA) across various European countries using a wide range of SEP indicators, including family-based (education, family affluence, perceived social standing, parents’ employment, housing tenure) and adolescent-based (academic performance and pocket money) ones.

Methods

We used data from a survey among 10,510 students aged 14–17 from 50 schools in six European cities: Namur (BE), Tampere (FI), Hannover (DE), Latina (IT), Amersfoort (NL), Coimbra (PT). The questionnaire included socio-demographic characteristics and the amount of time spent in VPA.

Results

The mean time spent practicing VPA was 60.4 min per day, with lower values for Namur (BE) and Latina (IT), and higher values for Amersfoort (NL). In the multivariable analysis, both categories of SEP indicators (family-based and adolescent based indicators) were independently associated with VPA. For each SEP indicator, lower levels of VPA were recorded in lower socioeconomic groups. In the total sample, each additional category of low SEP was associated with a decrease in mean VPA of about 4 min per day.

Conclusions

This study showed that across European cities adolescent VPA is positively related to both family-based SEP and adolescents’ own SEP. When analysing socioeconomic differences in adolescent VPA, one should consider the use of multiple indicators of SEP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10791-z.

The social gradient in smoking: individual behaviour, norms and nicotine dependence in the later stages of the cigarette epidemic

The cigarette epidemic tends to develop in a similar pattern across diverse populations in different parts of the world. First, the prevalence of smoking increases, then it plateaus and finally it declines. The decline in smoking prevalence tends to be more pronounced in higher social strata. The later stages of the cigarette epidemic are characterized by emerging and persisting socioeconomic gradients in smoking. Due to its detrimental health consequences, smoking has been the subject of extensive research in a broad range of academic disciplines. I draw on literature from both the social and medical sciences in order to develop a model in which physiological nicotine dependence, individual smoking behaviour and norms surrounding smoking in the immediate social environment are related through reflexive processes. I argue that the emergence and persistence of social gradients in smoking at the later stages of the cigarette epidemic can be attributed to a combination of the pharmacological properties of nicotine, network homophily and the unequal distribution of material and non-material resources across social strata.

The effect of school smoke-free policies on smoking stigmatization: A European comparison study among adolescents

The increasing denormalization of smoking by tobacco control policies and a normative smoke-free climate may shift power towards adolescent non-smokers. It is unclear, however, how common stigmatization of smokers is among adolescents or how stigmatization relates to the denormalization of smoking in their school and social environment. This paper aims to measure (1) whether stigmatization among European adolescents varies according to smoking status and socioeconomic position (SES), and (2) whether stigmatization is greater in school environments in which smoking is denormalized (i.e. those with low smoking rates and strong school tobacco policies). Data on 12,991 adolescents were collected in 55 schools in seven European countries (SILNE R-survey, 2016/17). We applied Stuber’s adapted scale of perceived stereotyping and discrimination towards smokers to smoking status and five variables indicating a power shift towards non-smokers: the school’s tobacco control policy (STP) score, the percentage of adolescents in the school who smoke, parents’ level of education, students’ academic performance, and the percentage of their friends who smoke. Multilevel regressions were applied to the global score for perceived stigmatization. Discrimination against smokers and stereotyping of smokers were frequently reported. Smokers reported less ‘perceived stigmatization of smoking’ than non-smokers (Beta = -0.146, p < 0.001). High-SES students reported stereotyping and discrimination more frequently than lower-SES students. The perception of stigmatization was lower among students whose academic performance was poor (Beta = -0.070, p < 0.001) and among those who had friends who smoked (Beta = -0.141, p < 0.001). Stigmatization was lower in schools with greater exposure to smoking and was not associated with the school’s STP score. Perceived stigmatization of smoking is common among European adolescents. Smokers themselves, however, perceive stigmatization less often than non-smokers. Strong school tobacco policies do not increase stigmatization, but a social environment that is permissive of smoking decreases perceived stigmatization.

Smoking behavior prevalence in one's personal social network and peer's popularity: A population-based study of middle-aged adults in Japan

Although previous social network studies have consistently shown the social influence of peers' smoking on one's (ego's) smoking, few studies have examined how the influence differs according to peers' structural positions in the network. Investigations are also lacking on whether vulnerability to the influence varies by ego's socioeconomic position. Thus, the present study aimed to examine how the association between peers' smoking and ego's smoking differs by peers' popularity in ego's personal network and ego's educational attainment. We used data from the third-wave Japanese Study on Stratification, Health, Income, and Neighborhood (J-SHINE) conducted in 2017, which targeted middle-aged (32-58-year-old) residents in four municipalities within Japanese metropolitan areas. Information on four close peers' characteristics and behaviors and their mutual relationships was collected by the name generator and name interpreter methods. Data on 1989 respondents and 7956 peers were evaluated. Peers' eigenvector centrality was used as their popularity index in ego's personal network. We set ego's smoking as an outcome, regressed on each peer's smoking, each peer's popularity, and ego's educational attainment adjusting for ego's age, sex, working status, marital status, spouse's/partner's smoking status, as well as similarity in socioeconomic backgrounds between peer and ego, using a logistic regression model with robust standard errors. We then added a three-way interaction term for these three explanatory variables to the model. Results showed that peer's smoking status was related to ego's smoking even more strongly when the peer was popular but only in the case of ego with lower educational attainment. The results suggested that the disparity in smoking behavior across socioeconomic positions may be partly explained by susceptibility to social influence from one's personal network among the socioeconomically vulnerable. This study proposes a plausible method for pinpointing the peer influencer in one's personal social network to close the socioeconomic gap in smoking.

The association between personal income and smoking among adolescents: a study in six European cities

AIMS

This study investigates the link between personal income and smoking among adolescents, and aims to answer the following questions: (i) to what extent is personal income related to smoking, independent of family socio-economic status (SES) and (ii) does the association between personal income and smoking apply to different subpopulations?

DESIGN

Cross-sectional study.

SETTING

Six cities from European countries (Amersfoort, the Netherlands; Coimbra, Portugal; Hannover, Germany; Latina, Italy; Namur, Belgium; Tampere, Finland) in 2013.

PARTICIPANTS

A school-based sample of 10 794 adolescents aged 14-17 years.

MEASUREMENTS

We modelled smoking experimentation, weekly smoking, daily smoking and (among daily smokers) smoking intensity as function of personal income, adjusting for age, sex, family SES, parental smoking and country. We tested interactions between personal income and covariates. Stratification analyses were performed for the variables for which interactions were significant.

FINDINGS

Adolescents in the highest income quintile were more likely to be smoking experimenters [odds ratio (OR) = 1.87; P < 0.01], weekly smokers (OR = 3.51; P < 0.01) and daily smokers (OR = 4.55; P < 0.01) than those in the lowest quintile. They also consumed more cigarettes per month (β = 0.79; P < 0.01). Adjusting for family SES did not modify the significance of relationships, and increased the magnitude of the association for daily smoking. None of the interactions between covariates and personal income was significant for smoking measures. For the intensity of smoking, the interaction was significant for SES. The stratified analysis showed a non-significant association between smoking intensity and personal income among the oldest adolescents and those with the lowest SES background, while significant among younger and higher SES backgrounds.

CONCLUSION

In the Netherlands, Portugal, Germany, Italy, Belgium and Finland, adolescents' personal income is related positively to smoking behaviours independent of family socio-economic status (SES). However, among low socio-economic status adolescent daily smokers, the association between the intensity of smoking and personal income is weaker.

The role of self-control and cognitive functioning in educational inequalities in adolescent smoking and binge drinking

Background

Large differences in substance use between educational levels originate at a young age, but there is limited evidence explaining these inequalities. The aim of this study was to test whether a) smoking and binge drinking are associated with lower levels of self-control and cognitive functioning, and b) associations between educational track and smoking and binge drinking, respectively, are attenuated after controlling for self-control and cognitive functioning.

Methods

This study used cross-sectional survey data of 15 to 20-year-olds (N = 191) from low, middle, and high educational tracks. We measured regular binge drinking and regular smoking (more than once a month), cognitive functioning (cognitive ability, reaction time and memory span), and self-control. Logistic regression models were used to assess the associations between educational track and smoking and binge drinking controlled for age, gender and social disadvantage, and for self-control and cognitive functioning.

Results

According to models that controlled for age, gender and social disadvantage only, respondents in the low educational track were more likely to drink heavily (OR = 3.25, 95% CI = 1.48–7.17) and smoke (OR = 5.74, 95% CI = 2.31–14.29) than adolescents in the high educational track. The association between educational track and binge drinking was hardly reduced after adjustment for self-control and cognitive ability (OR = 2.88, 95% CI = 1.09–7.62). Adjustment for self-control and cognitive functioning, especially cognitive ability, weakened the association between education and smoking (OR = 3.40, 95% CI = 1.11–10.37). However, inequalities in smoking remained significant and substantial.

Conclusions

In this study population, pre-existing variations between adolescents in terms of self-control and cognitive functioning played a minor role in educational inequalities in smoking, but not in binge drinking.

Changes in support for bans of illicit drugs, tobacco, and alcohol among adolescents and young adults in Europe, 2008-2014

Objectives

This study assessed the support for bans for tobacco, alcohol, and illicit drugs in adolescents and young adults across the European Union (EU).

Methods

Data were analysed for the years 2008, 2011, and 2014 for 27 EU member states. 37,253 individuals aged 15–24 years were interviewed ascertaining their support for banning tobacco, alcohol, cannabis, cocaine, heroin, and ecstasy. Changes over time were assessed using multilevel logistic regression.

Results

Support for banning heroin, ecstasy, and cocaine was constantly greater than 90%, although support fell over time. Support for cannabis ban declined (from 67.6% in 2008 to 53.7% in 2014) as well as support for alcohol ban (from 8.9% in 2008 to 6.9% in 2014) and tobacco ban (from 17.9% in 2008 to 16.5% in 2014).

Conclusions

Support for banning substances among EU adolescents and young adults varied, with high support for heroin, cocaine, and ecstasy, but less support for banning cannabis, tobacco, and alcohol. There was reduction in support of banning all substances between 2008 and 2014, but this varied substantially between European countries.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-017-1025-y) contains supplementary material, which is available to authorized users.

Childhood adversities and chronic conditions: examination of mediators, recall bias and age at diagnosis

OBJECTIVES

The aim of this study was to (1) identify the influence of childhood socioeconomic status (CSES) on five chronic conditions: asthma, bronchitis, hypothyroid, migraine, and psychiatric disorders in later life; (2) determine the mediating role of childhood abuse (CA) in these associations, and (3) quantify recall bias due to respondent's mental health in these associations.

METHODS

10,325 men and women from the Tromsø Study were followed for 13 years, and Poisson regression models were used.

RESULTS

Low CSES was associated with a 16-23% higher risk of chronic conditions, and CA was associated with a 16-58% higher risk of chronic conditions (p < 0.05). A minor proportion of the association between CSES and CA (3.98%, p < 0.05); CSES and chronic conditions (5.54-8.71%, p < 0.05); and CA and chronic conditions (9.51-19.52%, p < 0.05), were driven by recall bias due to the respondent's mental health. CA mediated the association between CSES and chronic conditions (9.58-25.06%, p < 0.05).

CONCLUSIONS

Low CSES and CA are associated with higher risk of chronic conditions in later life. A minor proportion of these associations are driven by recall bias.