Cross-national sources of health inequality: education and tobacco use in the World Health Survey

The mortality of oral cancer attributable to tobacco in China, the US, and India

PURPOSE

Assessing the mortality rates associated with tobacco-related oral cancer (OC) is crucial for effective allocation of resources within healthcare and economic systems.

METHODS

In this study, data from the Global Burden of Disease Study (GBD) 2019 were utilized to analyze the burden of tobacco-attributable OC in China, the United States (US), and India from 1990 to 2019. Descriptive statistics and an age-period-cohort model were employed to examine and compare the effects on OC mortality.

RESULTS

1. Attributable to tobacco, the deaths remained stable in the US, but increased in China and India. The trend of age-standardized mortality rate of OC increased in China, and decreased in the US and India, whereas the rate in India was the highest. 2. According to the APC model, the risk of death increased with age in all three countries. The period and later birth cohort effects were identified as risk factors in China and India, while in the US, the previous cohorts were identified as a risk factor. Except for India, males faced higher death risk than females in China and the US.

CONCLUSIONS

The burden of OC attributable to tobacco remains substantial in China and India. Public health officials in these countries should implement prevention and treatment strategies for OC, and interventions aimed at regulating the tobacco industry. The elderly is at an elevated risk for OC, and medical resources and policies should be directed toward this population. The successes experience in tobacco control and OC prevention in the US may serve as a model for other countries.

Summary and Concluding Remarks: Patterns of Birth Cohort‒Specific Smoking Histories

The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group age-period-cohort methodology to study smoking patterns can be applied to tackle important issues in tobacco control and public health. This paper summarizes the analyses of smoking patterns in the U.S. by race/ethnicity, educational attainment, and family income and for each of the 50 U.S. states using the CISNET Lung Working Group age-period-cohort approach. We describe how decision makers, policy advocates, and researchers can use the sociodemographic analyses in this supplement to project state smoking trends and develop effective state-level tobacco control strategies. The all-cause mortality RR estimates associated with smoking for U.S. race/ethnicity and education groups are also discussed in the context of research that measures and evaluates health disparities. Finally, the application of the CISNET Lung Working Group age-period-cohort methodology to Brazil is reviewed with a view to how the same types of analyses can be applied to other low- and middle-income countries.

Income-related inequality in smoking habits: A comparative assessment in the European Union

This paper investigates the association between income and the habit of smoking in 30 European countries. Using the European Health Interview Survey carried out between 2013 and 2015, the analysis focuses on the relationship among net monthly equivalised income of the household, the type of smoking behaviour, and the daily average number of cigarettes smoked. Income-related inequalities are estimated using the Erreygers Index. Results show that smoking is a habit which is mainly rooted in the lowest part of the income distribution both at individual and country level, regardless of the average level of per capita income. Considering that tobacco use worsens poverty conditions by diverting household spending from basic needs to tobacco itself, our results give support to a tax increase in order to discourage its use and to the implementation of educational and prevention programs aimed at helping people to quit smoking.

A dichotomy of smokers in the Philippines following sin tax reform: Distinguishing potential quitters from those unlikely to quit

The Philippine government significantly raised cigarette excise taxes in 2013, following passage of the landmark Sin Tax Reform Act of 2012. As a result, cigarette prices increased substantially. Given varying smokers’ responses to the price increase, we examined underlying typologies of Filipino smokers and assessed how these typologies determine smoking intensity. We used cross-sectional data from the 2015 wave of the Philippine Global Adult Tobacco Survey (N = 1,651). To uncover typologies, random effects latent class modelling was used on six individual smoker responses (attempting to stop, thinking about quitting, decreasing sticks smoked, switching to cheaper brands, buying in bulk, and asking from others). Bivariate and multivariate analyses were employed to uncover determinants of typologies and smoking intensity. We found two typologies based on smokers’ response. The first group, called “potential quitters” (62.62%), is composed of smokers who are more likely to consider quitting and decrease sticks smoked. The second group, called “unlikely to quit” (37.38%), have smokers who opt for price-minimization strategies like switching to cheaper brands, buying in bulk, or asking cigarettes from others. Potential quitters tend to be female, a student, and less nicotine dependent. They smoke up to three fewer sticks than those unlikely to quit, controlling for other factors. Nicotine dependence stood out as the most important predictor of being in the unlikely to quit group. The dominant role of nicotine dependence in determining a smoker’s typology points to the need for non-price based measures, such as those targeted towards highly-nicotine dependent smokers, to complement tax-induced price increases and comprehensively address the smoking problem.

Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries

OBJECTIVES

To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries.

DESIGN

Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020.

SETTING

Population based survey data.

PARTICIPANTS

1 231 068 individuals aged 15 years and older.

MAIN OUTCOME MEASURES

Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco).

RESULTS

The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age.

CONCLUSIONS

Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

What Regional Living Conditions Affect Individual Smoking of Adults in Russia

Objectives: Our study evaluated the impact of a wide range of characteristics of large administrative regions on the individual level of cigarette smoking in the Russian adult population. Methods: The pool of participants included 20,303 individuals aged 25-64 years. We applied 64 characteristics of the 12 Russian regions under study for 2010-2014. Using principal component analysis, we deduced five evidence-based composite indices of the regions. We applied the generalized estimating equation to determine associations between the regional indices and the individual level of smoking. Results: The increased Industrial index in the region is associated with the probability of smoking (odds ratio = 1.15; 95% confidence interval = 1.06-1.24). The other indices show associations with smoking only in separate gender and educational groups. Surprisingly, it was found that the Economic index has no associations with the probability of smoking. Conclusion: We evaluated the key associations of the territorial indices with the individual probability of smoking, as well as the mutual influence between the territorial indices and individual factors.

Socioeconomic inequalities in tobacco smoking in women aged 15-54 in Iran: a multilevel model

Significant evidence suggests an inverse relationship between socioeconomic status and tobacco smoking, where inequality is visible among different social and economic strata. The aim of this study was to investigate the prevalence and economic and social inequalities in tobacco smoking in women aged 15-54 in Iran. This study is a cross-sectional study. Sampling in this study was a randomized clustered multistage sampling with equal clusters. A total of 35,305 women aged 15-55 enrolled in the study. Data analysis was in two stages. In the first stage, the social and economic inequalities were investigated using the concentration index and concentration curve method, and in the second method, and multilevel method was used to identify the determinants. The prevalence of tobacco smoking in women was 12.24%. The concentration index for smoking was CI = -0.07 [95% CI (-0.09, -0.05)], which represents smoking in people with low socioeconomic status. The results of the multilevel analysis indicated that the marital status of people over the age of 35 and the economic class was related to smoking in women. Inequality in tobacco smoking in women is to the interest of the well-off group, and this inequality varies in different provinces. Marital status, place of residence, age and socioeconomic status of women are factors influencing the prevalence of tobacco smoking in women, and these issues should be noticed to reduce inequalities.

Inequalities in health-related quality of life and the contribution from socioeconomic status: evidence from Tibet, China

Background

This study aimed to understand the association between socioeconomic status (SES) and Health Related Quality of Life (HRQoL) and the contribution of SES to health inequality among Tibetans of agricultural and pastoral areas (APA) in Tibet, China.

Methods

The data were from Health Survey of Tibetans in APA conducted in 2014. A total of 816 respondents were enrolled for the analysis Multiple linear regression was employed to examine the relationship between SES and HRQoL. Concentration index (CI) was used to measure the degree of health inequality and a Wagstaff-type CI decomposition method was applied to measure the contribution of SES to inequality.

Results

SES had significant association with HRQoL among the Tibetans in APA. The high SES group was more likely to have a higher Eq-5d index (0.77 vs. 0.67, P < 0.001) and VAS (72.94 vs. 62.41, P < 0.001) than the low SES group. The Concentration index of the Eq-5d index and VAS for total sample was 0.022 and 0.026 respectively, indicating a slight pro-rich inequality among this population. The decomposition analyses showed the SES is the main contributor to health inequality and contributed 45.50 and 41.39% to inequality for the Eq-5d index and VAS, respectively.

Conclusion

The results showed SES is positively associated with HRQoL among Tibetans in APA. There was a slight pro-rich inequality in the health of the participants and most health inequality was attributable to SES. This study is helpful in gaining an insight into the HRQoL, health inequality and the relationship between SES and health inequality among Tibetans of APA in China.

The impact of social determinants of health on laryngotracheal stenosis development and outcomes

OBJECTIVES

The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome.

METHODS

Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow-up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey.

RESULTS

One hundred twenty-two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio [OR]: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis.

CONCLUSION

Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at-risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow-up.

LEVEL OF EVIDENCE

Level 3, retrospective review comparing cases and controls Laryngoscope, 130:1000-1006, 2020.

Social determinants of dual tobacco use in India: An analysis based on the two rounds of global adult tobacco survey

•

First study from India and south Asia examining trends and socioeconomic predictor of dual tobacco use.

•

Considerable disparity in dual tobacco use across socioeconomic groups evident.

•

Time adjusted result show various factors that determined dual tobacco use.

•

There is a need for targeted cessation interventions among dual tobacco users as no proven pharmocological or behavioural cessation model exists for them.

This study examines the socioeconomic determinants of dual use of smoked and smokeless tobacco (SLT) in India between 2009–10 and 2016–17. Data from two rounds of the nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009–10 and 2016–17 was used. Complete sample size from both rounds of survey covering 143,333 individuals (GATS I: 69,296 and GATS II: 74,037) from 153,239 households (GATS I: 76,069 and GATS II: 77,170) included in the study. Dual use was assessed based on current smoked and SLT users in both rounds. Bivariate analysis was applied to assess differences in dual tobacco use by socioeconomic status (SES) and across regions, whereas, pooled sampled analysis was conducted to examine the determinants of dual use applying multinomial logistic regression model. Findings reveal that dual use has declined in India from nearly 5% in 2009–10 to 3.4% in 2016–17. Considerable regional and SES differences in dual use are evident. Multivariate results indicate, while age is positively associated with dual use, education and household wealth was negatively associated. Dual use of tobacco was found to be considerably higher among men as compared to women (RRR: 15.66, 95%CI 14.20–17.27). Awareness about the adverse health consequences of tobacco was also negatively associated with dual tobacco use (RRR: 0.56, 95%CI 0.50–0.64). Future awareness and enforcement efforts should focus on all forms of tobacco, especially targeting vulnerable SE groups.

24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

The educational gap in tar and nicotine content in purchases of cigarettes: An observational study using large-scale representative survey data from Japan

The intensity of tobacco use is commonly measured by the number of cigarettes, which is inaccurate because it masks the heterogeneity and substances contained in tobacco. Unlike existing studies, this study adopted the tar and nicotine content of purchased cigarettes as proxies for smoking intensity and elicited socioeconomic disparities from the participants regarding tobacco use. Using a nationally representative consumer panel survey of Japan from 2010 to 2014, we found that socioeconomic disparities in smoking are more pronounced when tar and nicotine content in cigarettes is considered. University graduates purchased 26% fewer cigarettes, and 40% less tar or nicotine than their secondary school-educated counterparts. Low education groups purchased more tar-rich cigarettes, which cost less than low-tar cigarettes. The public health recommendations for reducing socioeconomic health inequalities might be understated because they are drawn from evidence based on the number of cigarettes smoked.

Estimation of the Risk of Lung Cancer in Women Participating in a Population-Based Breast Cancer Screening Program

INTRODUCTION

Lung cancer mortality is increasing in women. In Spain, estimates suggest that lung cancer mortality may soon surpass breast cancer mortality, the main cause of cancer mortality among women. The aim of this study was to estimate the proportion of women at high risk of developing lung cancer in a group of participants in a population-based breast cancer screening program.

METHODS

Cross-sectional study in a sample of women who participated in a population-based breast cancer screening program in 2016 in Hospitalet de Llobregat (n=1,601). High risk of lung cancer was defined according to the criteria of the National Lung Screening Trial (NLST) and the Dutch-Belgian randomized lung cancer screening trial (NELSON).

RESULTS

Around 20% of smokers according to NLST criteria and 40% of smokers according to NELSON criteria, and around 20% of former smokers according to both criteria, are at high risk of developing lung cancer. A positive and statistically significant trend is observed between the proportion of women at high risk and nicotine dependence measured with the brief Fagerström test.

CONCLUSIONS

A high proportion of participants in this breast cancer screening program have a high risk of developing lung cancer and would be eligible to participate in a lung cancer screening program. Population-based breast cancer screening programs may be useful to implement lung cancer primary prevention activities.

Epigenetic signatures of smoking associate with cognitive function, brain structure, and mental and physical health outcomes in the Lothian Birth Cohort 1936

Recent advances in genome-wide DNA methylation (DNAm) profiling for smoking behaviour have given rise to a new, molecular biomarker of smoking exposure. It is unclear whether a smoking-associated DNAm (epigenetic) score has predictive value for ageing-related health outcomes which is independent of contributions from self-reported (phenotypic) smoking measures. Blood DNA methylation levels were measured in 895 adults aged 70 years in the Lothian Birth Cohort 1936 (LBC1936) study using the Illumina 450K assay. A DNA methylation score based on 230 CpGs was used as a proxy for smoking exposure. Associations between smoking variables and health outcomes at age 70 were modelled using general linear modelling (ANCOVA) and logistic regression. Additional analyses of smoking with brain MRI measures at age 73 (n = 532) were performed. Smoking-DNAm scores were positively associated with self-reported smoking status (P < 0.001, eta-squared ɳ2 = 0.63) and smoking pack years (r = 0.69, P < 0.001). Higher smoking DNAm scores were associated with variables related to poorer cognitive function, structural brain integrity, physical health, and psychosocial health. Compared with phenotypic smoking, the methylation marker provided stronger associations with all of the cognitive function scores, especially visuospatial ability (P < 0.001, partial eta-squared ɳp2 = 0.022) and processing speed (P < 0.001, ɳp2 = 0.030); inflammatory markers (all P < 0.001, ranges from ɳp2 = 0.021 to 0.030); dietary patterns (healthy diet (P < 0.001, ɳp2 = 0.052) and traditional diet (P < 0.001, ɳp2 = 0.032); stroke (P = 0.006, OR 1.48, 95% CI 1.12, 1.96); mortality (P < 0.001, OR 1.59, 95% CI 1.42, 1.79), and at age 73; with MRI volumetric measures (all P < 0.001, ranges from ɳp2 = 0.030 to 0.052). Additionally, education was the most important life-course predictor of lifetime smoking tested. Our results suggest that a smoking-associated methylation biomarker typically explains a greater proportion of the variance in some smoking-related morbidities in older adults, than phenotypic measures of smoking exposure, with some of the accounted-for variance being independent of phenotypic smoking status.

Family Change in Global Perspective: How and Why Family Systems Change

Changes in family systems that have occurred over the past half century throughout the Western world are now spreading across the globe to nations that are experiencing economic development, technological change, and shifts in cultural beliefs. Traditional family systems are adapting in different ways to a series of conditions that forced shifts in all Western nations. In this paper, I examine the causes and consequences of global family change, introducing a recently funded project using the Demographic and Health Surveys (DHS) and U.S. Census Bureau data to chart the pace and pattern of changes in marriage and family systems in low- and middle-income nations.

Relationship between Food Dependence and Nicotine Dependence in Smokers: A Cross-Sectional Study of Staff and Students at Medical Colleges

Background and objectives: The aim of this study was to examine the relationship between nicotine dependence and food dependence in smokers. Smoking and obesity are both serious public health problems that give rise to diseases and increased medical expenses. Nicotine dependence is one of the sources of difficulty in smoking cessation, while food dependence is one of the causes of obesity. Materials and Methods: We examined the data of 72 (smoking vs. nonsmoking) and 62 (nicotine dependence vs. no nicotine dependence) subjects among 321 staff and students at medical colleges in Kagawa and Okayama prefectures in Japan. Results: There was a significant difference in food dependence (except women) between the smoking and nonsmoking groups (total: smoking 4.7 ± 6.1, nonsmoking 2.1 ± 2.0, p = 0.0411; men: smoking 4.0 ± 4.7, nonsmoking 2.0 ± 2.1, p = 0.0490). There was also a significant difference in food dependence (except women) between the nicotine dependence and no nicotine dependence groups (total: nicotine dependence 4.6 ± 6.3, no nicotine dependence 2.0 ± 2.1, p = 0.0370; men: nicotine dependence 3.6 ± 4.8, no nicotine dependence 1.6 ± 1.8, p = 0.0489). Conclusion: The findings showed that the smoking group (and nicotine dependence group) had higher food dependence than the nonsmoking group (and no nicotine dependence group). Our results indicate an interdependence between nicotine and food dependences.

Association between depression and smoking: A global perspective from 48 low- and middle-income countries

BACKGROUND

Smoking is a leading modifiable cause of global morbidity and mortality. Research from high-income countries has found a high prevalence of smoking among people with depression and suggested that this may partially contribute to the increased premature mortality in this population. Limited research has investigated smoking behaviors across the depression spectrum and in low- and middle-income countries (LMICs). This study explored the relationship between depression and smoking across 48 LMICs.

METHODS

We conducted a cross-sectional, community-based study comprising 242,952 people [mean age 38.4 (SD = 16.1) years, 50.8% females] from the World Health Survey. Multivariable binary logistic regression analyses were performed to investigate the relationship between depression (including subsyndromal, brief depressive episode and depressive episodes) and smoking behaviours.

RESULTS

Overall, the prevalence of current smoking was lowest in Africa (13.5%) and highest in Asia (32.2%). A depressive episode was present in 6.7% of the sample. Compared to people without depression, subsyndromal depression, brief depressive episode, and depressive episodes were all significantly associated with smoking with similar effect sizes (ORs: 1.36-1.49). Countrywide meta-analysis found that the pooled overall OR for smoking in depression was 1.42 (95%CI = 1.32-1.52, I² = 39.7%). Furthermore, alcohol consumption and male gender were consistently associated with smoking across all regions and smoking was consistently less common in those who were wealthier and had a higher education.

CONCLUSION

These data suggest that the depression spectrum is consistently associated with high levels of smoking behaivours in LMICs. Given that most of the world's smokers reside in LMICs, future smoking cessation interventions are required to target people with depression.

Socio-Economic Inequalities in Tobacco Consumption of the Older Adults in China: A Decomposition Method

Background: In China, tobacco consumption is a leading risk factor for non-communicable diseases, and understanding the pattern of socio-economic inequalities of tobacco consumption will, thus, help to develop targeted policies of public health control. Methods: Data came from the China Health and Retirement Longitudinal Study in 2013, involving 17,663 respondents aged 45 and above. Tobacco use prevalence and tobacco use quantities were defined for further analysis. Using the concentration index (CI) and its decomposition, socio-economic inequalities of tobacco consumption grouped by gender were estimated. Results: The concentration index of tobacco use prevalence was 0.044 (men 0.041; women −0.039). The concentration index of tobacco use quantities among smokers was 0.039 (men 0.033; women 0.038). The majority of the inequality could be explained by educational attainment, age, area, and economic quantiles. Conclusions: Tobacco consumption was more common among richer compared to poorer people in China. Gender, educational attainments, age, areas, and economic quantiles were strong predictors of tobacco consumption in China. Public health policies need to be targeted towards men in higher economic quantiles with lower educational attainment, and divorced or widowed women, especially in urban areas of China.

Educational inequalities in risky health behaviours in 21 European countries: findings from the European social survey (2014) special module on the social determinants of health

Background

It has been suggested that cross-national variation in educational inequalities in health outcomes (e.g. NCDs) is due to cross-national variation in risky health behaviour. In this paper we aim to use highly recent data (2014) to examine educational inequalities in risky health behaviour in 21 European countries from all regions of the continent to map cross-national variation in the extent to which educational level is associated with risky health behaviour. We focus on four dimensions of risky health behaviour: smoking, alcohol use, lack of physical activity and lack of fruit and vegetable consumption.

Methods

We make use of recent data from the 7th wave of the European Social Survey (2014), which contains a special rotating module on the social determinants of health. We performed logistic regression analyses to examine the associations between educational level and the risky health behaviour indicators. Educational level was measured through a three-category version of the harmonized International Standard Classification of Education (ISCED).

Results

Our findings show substantial and mostly significant inequalities in risky health behaviour between educational groups in most of the 21 European countries examined in this paper. The risk of being a daily smoker is higher as respondents’ level of education is lower (Low education (L): OR = 4.24 (95% CI: 3.83–4.68); Middle education (M): OR = 2.91 (95% CI: 2.65–3.19)). Respondents have a lower risk of consuming alcohol frequently if they have a low level of education (L: OR = 0.59 (95% CI: 0.54–0.64); M: OR = 0.70 (95% CI: 0.65–0.76)), but a higher risk of binge drinking frequently (L: OR = 1.29 (95% CI: 1.16–1.44); M: OR = 1.15 (95% CI: 1.04–1.27)). People are more likely to be physically active at least 3 days in the past week when they have a higher level of education (M: OR = 1.42 (95% CI: 1.34–1.50); H: OR = 1.67 (95% CI: 1.55–1.80)). Finally, people are more likely to consume fruit and vegetables at least daily if they have a higher level of education (fruit: M: OR = 1.09 (95% CI: 1.03–1.16); H: OR = 1.77 (95% CI: 1.63–1.92); vegetables: M: OR = 1.34 (95% CI: 1.26–1.42); H: OR = 2.35 (95% CI: 2.16–2.55)). However, we also found considerable cross-national variation in the associations between education and risky health behaviour.

Conclusions

Our results yield a complex picture: the lowest educational groups are more likely to smoke and less likely to engage in physical activity and to eat fruit and vegetables, but the highest educational groups are at greater risk of frequent alcohol consumption. Additionally, inequalities in risky health behaviour do not appear to be systematically weakest in the South or strongest in the North and West of Europe.

Perceived stress and smoking across 41 countries: A global perspective across Europe, Africa, Asia and the Americas

Within recent years, there has been a seismic shift in smoking rates from high-income to low- and middle-income countries (LMICs). Evidence indicates that perceived stress may comprise a barrier for smoking cessation, but little is known about the association of perceived stress and smoking in LMICs. We conducted a cross-sectional, community-based study comprising 217,561 people [mean age 38.5 (SD = 16.1) years, 49.4% males]. A perceived stress score [range 2 (lowest-stress) 10 (highest-stress)] was computed from the Perceived Stress Scale. Multivariable logistic regression analyses were conducted. In the overall sample, a one-unit increase in perceived-stress resulted in a 5% increased odds of smoking (OR = 1.05; 95%CI = 1.03–1.06). Increased stress was associated with smoking in Africa (OR = 1.06; 95%CI = 1.04–1.09), Americas (OR = 1.03; 95%CI = 1.01–1.05), and Asia (OR = 1.06; 95%CI = 1.04–1.08), but not Europe (OR = 0.99; 95%CI = 0.95–1.02). Increasing levels of perceived stress were significantly associated with heavy smoking (≥30 cigarettes per day) among daily smokers (OR = 1.08; 95%CI = 1.02–1.15). A country-wide meta-analysis showed that perceived stress is associated with daily smoking in most countries. Prospective studies are warranted to confirm/refute this relationship, which may have meaningful public health implications.

Cross-cultural variation in the association between family's socioeconomic status and adolescent alcohol use

INTRODUCTION AND AIMS

This study estimates cross-country variation in socioeconomic disparities in adolescent alcohol use and identifies country-level characteristics associated with these disparities.

DESIGN AND METHODS

The association between socioeconomic status (family wealth and parental education) and alcohol use (lifetime use and episodic heavy drinking) of 15- to 16-year-olds from 32 European countries was investigated. Country-level characteristics were national income, income inequality and per capita alcohol consumption. Multilevel modelling was applied.

RESULTS

Across countries, lifetime use was lower in wealthy than in less wealthy families (odds ratio [OR]_(girls)  = 0.95, OR_(boys)  = 0.94). The risk of episodic heavy drinking, in contrast, was higher for children from wealthier families (OR_(girls)  = 1.04, OR_(boys)  = 1.08) and lower when parents were highly educated (ORs = 0.95-0.98). Socioeconomic disparities varied substantially between countries. National wealth and income inequality were associated with cross-country variation of disparities in lifetime use in few comparisons, such that among girls, the (negative) effect of family wealth was greatest in countries with unequally distributed income (OR = 0.86). Among boys, the (negative) effect of family wealth was greatest in low-income countries (OR = 1.00), and the (positive) effect of mothers' education was greatest in countries with high income inequality (OR = 1.11).

DISCUSSION AND CONCLUSIONS

Socioeconomic disparities in adolescent alcohol use vary across European countries. Broad country-level indicators can explain this variation only to a limited extent, but results point towards slightly greater socioeconomic disparities in drinking in countries of low national income and countries with a high income inequality. [Gomes de Matos E, Kraus L, Hannemann T-V, Soellner R, Piontek D. Cross-cultural variation in the association between family's socioeconomic status and adolescent alcohol use.

Childhood cognitive ability and smoking initiation, relapse and cessation throughout adulthood: evidence from two British cohort studies

AIMS

To test the relationship between early cognitive ability and major changes in smoking habits across adulthood, and test whether educational attainment mediates these associations.

DESIGN

Prospective observational study to examine the link between cognitive ability and smoking initiation, relapse and cessation at multiple time-points throughout adulthood in a pooled analysis of two cohorts.

SETTING

Great Britain 1981-2013.

PARTICIPANTS

A total of 16 653 participants from two British cohorts; 7191 from the 1970 British Cohort Study (BCS) and 9462 from the 1958 National Child Development Study (NCDS). Participants were 52.9% female and 27.3% were smokers, 24.8% were ex-smokers and 47.9% reported never smoking.

MEASUREMENTS

Cognitive ability was assessed at age 10 years in the BCS and 11 years in the NCDS. Outcomes were smoking initiation, relapse and cessation derived from changes in smoking status observed across five time-points between ages 26-42 in the BCS and six time-points between ages 23-55 in the NCDS. Educational attainment was examined as a mediating variable. Controls were age, gender, social class, self-control, psychological distress, parental smoking and a study indicator (BCS/NCDS).

FINDINGS

In adjusted regression models, a 1 standard deviation increase in cognitive ability predicted a 0.5 percentage point (95% CI = -0.9 to -0.1) reduced probability of smoking and a 2.9 percentage point (95% CI = 2.1-3.7) higher probability of smoking cessation throughout adulthood, but did not change the likelihood of smoking relapse significantly. Differences in educational attainment explained approximately half the association between childhood cognitive ability and smoking initiation/cessation.

CONCLUSIONS

Lower cognitive ability, measured in childhood before smoking is initiated, appears to predict a higher likelihood of taking up smoking and a lower likelihood of quitting in adulthood. Educational attainment appears to mediate this effect: children with higher cognitive ability tend to become more highly educated adults which, in turn, predicts lower rates of smoking initiation and increased rates of smoking cessation.

Educational and wealth inequalities in tobacco use among men and women in 54 low-income and middle-income countries

BACKGROUND

Socioeconomic differentials of tobacco smoking in high-income countries are well described. However, studies to support health policies and place monitoring systems to tackle socioeconomic inequalities in smoking and smokeless tobacco use common in low-and-middle-income countries (LMICs) are seldom reported. We aimed to describe, sex-wise, educational and wealth-related inequalities in tobacco use in LMICs.

METHODS

We analysed Demographic and Health Survey data on tobacco use collected from large nationally representative samples of men and women in 54 LMICs. We estimated the weighted prevalence of any current tobacco use (including smokeless tobacco) in each country for 4 educational groups and 4 wealth groups. We calculated absolute and relative measures of inequality, that is, the slope index of inequality (SII) and relative index of inequality (RII), which take into account the distribution of prevalence across all education and wealth groups and account for population size. We also calculated the aggregate SII and RII for low-income (LIC), lower-middle-income (lMIC) and upper-middle-income (uMIC) countries as per World Bank classification.

FINDINGS

Male tobacco use was highest in Bangladesh (70.3%) and lowest in Sao Tome (7.4%), whereas female tobacco use was highest in Madagascar (21%) and lowest in Tajikistan (0.22%). Among men, educational inequalities varied widely between countries, but aggregate RII and SII showed an inverse trend by country wealth groups. RII was 3.61 (95% CI 2.83 to 4.61) in LICs, 1.99 (95% CI 1.66 to 2.38) in lMIC and 1.82 (95% CI 1.24 to 2.67) in uMIC. Wealth inequalities among men varied less between countries, but RII and SII showed an inverse pattern where RII was 2.43 (95% CI 2.05 to 2.88) in LICs, 1.84 (95% CI 1.54 to 2.21) in lMICs and 1.67 (95% CI 1.15 to 2.42) in uMICs. For educational inequalities among women, the RII varied much more than SII varied between the countries, and the aggregate RII was 14.49 (95% CI 8.87 to 23.68) in LICs, 3.05 (95% CI 1.44 to 6.47) in lMIC and 1.58 (95% CI 0.33 to 7.56) in uMIC. Wealth inequalities among women showed a pattern similar to that of men: the RII was 5.88 (95% CI 3.91 to 8.85) in LICs, 1.76 (95% CI 0.80 to 3.85) in lMIC and 0.39 (95% CI 0.09 to 1.64) in uMIC. In contrast to men, among women, the SII was pro-rich (higher smoking among the more advantaged) in 13 of the 52 countries (7 of 23 lMIC and 5 of 7 uMIC).

INTERPRETATION

Our results confirm that socioeconomic inequalities tobacco use exist in LMIC, varied widely between the countries and were much wider in the lowest income countries. These findings are important for better understanding and tackling of socioeconomic inequalities in health in LMIC.

The impact of cigarette smoking on life expectancy between 1980 and 2010: a global perspective

INTRODUCTION

Tobacco smoking is among the leading causes of preventable mortality worldwide. We assessed the impact of smoking on life expectancy worldwide between 1980 and 2010.

METHODS

We retrieved cause-specific mortality data from the WHO Mortality Database by sex, year and age for 63 countries with high or moderate quality data (1980-2010). Using the time of the peak of the smoking epidemic by country, relative risks from the three waves of the Cancer Prevention Study were applied to calculate the smoking impact ratio and population attributable fraction. Finally, we estimated the potential gain in life expectancy at age 40 if smoking-related deaths in middle age (40-79 years) were eliminated.

RESULTS

Currently, tobacco smoking is related to approximately 20% of total adult mortality in the countries in this study (24% in men and 12% in women). If smoking-related deaths were eliminated, adult life expectancy would increase on average by 2.4 years in men (0.1 in Uzbekistan to 4.8 years in Hungary) and 1 year in women (0.1 in Kyrgyzstan to 2.9 years in the USA). The proportion of smoking-related mortality among men has declined in most countries, but has increased in the most populous country in the world, that is, China from 4.6% to 7.3%. Increases in the impact of tobacco on life expectancy were observed among women in high-income countries.

CONCLUSIONS

Recent trends indicate a substantial rise in the population-level impact of tobacco smoking on life expectancy in women and in middle-income countries. High-quality local data are needed in most low-income countries.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions

Background & objectives:

India is a large country with each State having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various States of India.

Methods:

Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across States and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation.

Results:

Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the States. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33)

Interpretation & conclusions:

The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the States in India.

Genome-Wide Estimates of Heritability for Social Demographic Outcomes

An increasing number of studies that are widely used in the demographic research community have collected genome-wide data from their respondents. It is therefore important that demographers have a proper understanding of some of the methodological tools needed to analyze such data. This article details the underlying methodology behind one of the most common techniques for analyzing genome-wide data, genome-wide complex trait analysis (GCTA). GCTA models provide heritability estimates for health, health behaviors, or indicators of attainment using data from unrelated persons. Our goal was to describe this model, highlight the utility of the model for biodemographic research, and demonstrate the performance of this approach under modifications to the underlying assumptions. The first set of modifications involved changing the nature of the genetic data used to compute genetic similarities between individuals (the genetic relationship matrix). We then explored the sensitivity of the model to heteroscedastic errors. In general, GCTA estimates are found to be robust to the modifications proposed here, but we also highlight potential limitations of GCTA estimates.

[Social inequalities in adolescent smoking: A cross-national perspective of the role of individual and macro-structural factors]

BACKGROUND

In an EU-funded project, we examined on the basis of international comparative analyses which factors were associated with and contributed to socioeconomic inequalities in adolescent smoking. This paper presents the results obtained and discusses their implications for policy and research.

METHODS

Analyses were based on the "Health Behaviour in School-aged Children (HBSC)" study in 2006 and included more than 50,000 adolescents from 37 countries. The focus was on the association between family affluence and weekly smoking (regularly, at least once a week) among adolescents. Explanatory variables at the individual level refer to psychosocial resources and burdens of school, family, and peers. At the country level, national income, various tobacco control policies, and an index of external differentiation of the educational system were used.

RESULTS

The psychosocial factors of school and family explained many of the inequalities in the smoking behavior of adolescents. In an international comparison, socioeconomic inequalities in smoking were stronger in richer countries. Absolute smoking rates were lower and inequalities in smoking smaller for boys in countries with higher tobacco prices. On the other hand, educational systems with higher degrees of external differentiation showed lower inequalities in smoking beahviour by girls, and relatively higher rates of smoking (for boys and girls). Stronger inequalities in smoking behaviour were demonstrated in countries with a greater range of preventative measures for tobacco dependence (for boys) and with higher levels of government spending on tobacco control (for girls).

CONCLUSION

Experiences in richer countries revealed that tobacco control needs to be strengthened for socially disadvantaged adolescents. The reduction of smoking prevalence and socioeconomic inequalities in smoking behavior should be based not only on a strengthening of psychosocial resources in the family and at school, but also on an increase in tobacco prices.

Examining the Effects of Parental Influence on Adolescent Smoking Behaviors: A Multilevel Analysis of the Global School-Based Student Health Survey (2003-2011)

INTRODUCTION

Based on a large cross-national dataset, we investigated the role of parental smoking (a risk factor) and parental supervision (a protective factor) on the frequency of smoking by youths in resource-poor countries. In addition, we tested for cross-level interactions between these two predictors and national wealth on the outcome variable.

METHODS

Pooled cross-sectional data from the Global School-based Student Health Survey (2003-2011) were analyzed, which consists of 58956 students in 31 countries. Hierarchical linear models were estimated to examine the associations between the two parental influence variables and adolescent smoking.

RESULTS

Among the control variables, age, gender (male), the experience of being bullied, frequency of getting into physical fights, truancy, and anxiety were significantly related to higher frequency of smoking. With respect to the main predictors, both at the individual level, parental supervision was negatively associated with adolescent smoking, while parental smoking was positively related to it. Two cross-level interaction terms were also observed. National wealth (GDP per capita) significantly moderated, that is, increased, these effects of parental influence on how often the adolescents smoked.

CONCLUSIONS

We provided new evidence on the factors related to adolescent smoking in low-income countries, a topic that has received very little attention. We showed that the associations between parental influences and adolescent smoking behaviors are not constant but vary according to the level of economic development. Future research should incorporate this comparative dimension in elaborating and specifying the conditions under which parental influences and other predictors differentially affect adolescent smoking.

IMPLICATIONS

Prior research on adolescent smoking focused on developed countries. Based on the secondary analysis of the Global School-based Student Health Survey (2003-2011), this study examines the associations between parental influence (parental smoking and parental supervision) on the frequency of youth smoking behaviors in resource-poor countries. We show that parental smoking is positively related to adolescent smoking, while parental supervision is negatively related to it. We also find that these two associations vary according to national wealth: both effects are stronger in a country with higher per capita GDP.

The Social Patterning of Tobacco Use Among Women in Jordan: The Protective Effect of Education on Cigarette Smoking and the Deleterious Effect of Wealth on Cigarette and Waterpipe Smoking

INTRODUCTION

The presence of social inequalities in tobacco-use has been fully recognized in the international literature. Even though cigarette and waterpipe tobacco smoking (WTS) are prevalent in the Arab region, the literature has not addressed the social determinants of the impending tobacco epidemic. This study examined the socioeconomic patterning of cigarette and WTS among Jordanian women.

METHODS

We analyzed pooled data from four waves of the Jordan Demographic and Health Surveys: 2002 (N = 5851); 2007 (N = 10 654); 2009 (N = 9879), and 2012 (N = 11 113). We specified logistic regression models to test the association between education and household wealth and the two outcome measures, cigarette and WTS, adjusting for other covariates. For each outcome, we ran time-unadjusted and time-adjusted logistic models.

RESULTS

Cigarette smoking prevalence among Jordanian women remained almost constant (around 10%) between 2002 and 2012. WTS prevalence steadily increased from 4.1% in 2002 to 10.2% in 2012. Increasing education predicted lower odds of cigarette smoking, whereas increasing household wealth weakly predicted higher odds. As to WTS, increasing household wealth strongly predicted higher odds of use.

CONCLUSIONS

Among Jordanian women, increasing education is protective against cigarette smoking. Household wealth, on the other hand, exerts a deleterious effect on both forms of tobacco consumption, particularly WTS. This pattern shows that Jordan has not fully undergone the socioeconomic crossover in tobacco prevalence which characterizes high-income countries. Future control policies should aim to decrease prevalence but also preempt increasing social inequalities in tobacco use.

A cross-sectional study of the prevalence and correlates of tobacco use in Chennai, Delhi, and Karachi: data from the CARRS study

Background

Tobacco burdens in India and Pakistan require continued efforts to quantify tobacco use and its impacts. We examined the prevalence and sociodemographic and health-related correlates of tobacco use in Delhi, Chennai (India), and Karachi (Pakistan).

Methods

Analysis of representative surveys of 11,260 participants (selected through multistage cluster random sampling; stratified by gender and age) in 2011 measured socio-demographics, tobacco use history, comorbid health conditions, and salivary cotinine. We used bivariate and multivariate regression analyses to examine factors associated with tobacco use.

Results

Overall, 51.8 % were females, and 61.6 % were below the age of 45 years. Lifetime (ever) tobacco use prevalence (standardized for world population) was 45.0 %, 41.3 %, and 42.5 % among males, and 7.6 %, 8.5 %, and 19.7 % among females in Chennai, Delhi, and Karachi, respectively. Past 6 month tobacco use prevalence (standardized for world population) was 38.6 %, 36.1 %, and 39.1 % among males, and 7.3 %, 7.1 %, and 18.6 % among females in Chennai, Delhi, and Karachi, respectively. In multivariable regression analyses, residing in Delhi or Karachi versus Chennai; older age; lower education; earning less income; lower BMI; were each associated with tobacco use in both sexes. In addition, semi-skilled occupation versus not working and alcohol use were associated with tobacco use in males, and having newly diagnosed dyslipidemia was associated with lower odds of tobacco use among females. Mean salivary cotinine levels were higher among tobacco users versus nonusers (235.4; CI: 187.0-283.8 vs. 29.7; CI: 4.2, 55.2, respectively).

Conclusion

High prevalence of tobacco use in the South Asian region, particularly among men, highlights the urgency to address this serious public health problem. Our analyses suggest targeted prevention and cessation interventions focused on lower socioeconomic groups may be particularly important.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1817-z) contains supplementary material, which is available to authorized users.

Current smoking is associated with lower seminal vesicles and ejaculate volume, despite higher testosterone levels, in male subjects of infertile couples

STUDY QUESTION

What is the impact of smoking behaviour on seminal, hormonal and male genital tract ultrasound parameters in subjects seeking medical care for couple infertility?

STUDY ANSWER

In males of infertile couples, current smokers (CS), when compared with non-smokers, show lower ejaculate and ultrasound-derived seminal vesicles (SV) volume, despite higher testosterone levels.

WHAT IS KNOWN ALREADY

Data on the effects of smoking on male fertility are conflicting. A correlation between smoking and reduced semen parameters has been reported, however, with a high heterogeneity among studies. An association between smoking behaviour and higher testosterone levels in men has been described in several, but not all, the previous studies. No study has systematically evaluated the impact of smoking on the male genital tract ultrasound characteristics.

STUDY DESIGN, SIZE AND DURATION

Retrospective cross-sectional analysis of a consecutive series of 426 subjects seeking medical care for couple infertility from January 2010 to July 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From the entire cohort, 394 men (age 36.0 ± 8.0 years) free of genetic abnormalities were selected. All subjects underwent a complete andrological and physical examination, biochemical and hormonal assessment, scrotal and transrectal colour-Doppler ultrasound and semen analysis (including seminal interleukin-8 levels, sIL-8) within the same day.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the patients evaluated, 229 were never smokers (NS), 56 past smokers (PS) and 109 CS. When CS were compared with the rest of the sample (non-smokers, NS + PS), in a multivariate model (analysis of covariance, ANCOVA) adjusted for age, lifestyle (including alcohol, cannabis and physical activity), BMI and sex hormone-binding globulin, significantly higher androgen (total testosterone, P = 0.001; calculated free testosterone, P < 0.005) and lower FSH (P < 0.05) levels were observed in CS. However, when total testosterone was also included in the multivariate model as a further covariate, the difference in FSH levels was not confirmed. In a similar model, a lower ejaculate volume (P < 0.01) and a higher prevalence of normal sperm morphology (P < 0.02) were also detected in CS in comparison with the rest of the sample. However, when total testosterone was also included in the multivariate model as a further covariate, only the difference in ejaculate volume between CS and non-smokers was confirmed (-0.61 ± 0.23 ml, P < 0.01). Finally, CS showed lower total SV volume, before and after ejaculation, even after adjusting for confounders (P = 0.02 and <0.01, respectively). Similar results were observed when the reported number of cigarettes smoked or the number of pack-years was considered separately.

LIMITATIONS, REASONS FOR CAUTION

The present results are derived from patients consulting an Andrology Clinic for couple infertility, who could have different characteristics from the general male population or males consulting general practitioners for reasons other than couple infertility. In addition, we did not have a true control group composed of age-matched, apparently healthy, fertile men, and therefore true normative data of sonographic parameters cannot be inferred. Due to the cross-sectional nature of our study, neither a causality hypothesis nor mechanistic models can be drawn. Finally, this is a retrospective study, and further prospective studies are required.

WIDER IMPLICATIONS OF THE FINDINGS

We report an apparent paradox in CS: lower SV volume despite higher testosterone levels. Our data suggest that smoking may negatively affect SV volume in an independent manner, as the difference between CS and non-smokers retained significance after adjusting for confounders including testosterone. This is the first study reporting such ultrasound evidence. How this new smoking-related alteration, along with low semen volume, impacts male fertility needs to be addressed by further studies.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for the study. None of the authors have any conflict of interest to declare.

The association between family affluence and smoking among 15-year-old adolescents in 33 European countries, Israel and Canada: the role of national wealth

AIMS

To examine the role of national wealth in the association between family affluence and adolescent weekly smoking, early smoking behaviour and weekly smoking among former experimenters.

DESIGN AND PARTICIPANTS

Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 in 35 countries from Europe and North America that comprises 60 490 students aged 15 years. Multi-level logistic regression was conducted using Markov chain Monte Carlo methods (MCMC) to explore whether associations between family affluence and smoking outcomes were dependent upon national wealth.

MEASUREMENT

Family Affluence Scale (FAS) as an indicator for the socio-economic position of students. Current weekly smoking behaviour is defined as at least weekly smoking (dichotomous). Early smoking behaviour is measured by smoking more than a first puff before age 13 years (dichotomous). Weekly smoking among former experimenters is restricted to those who had tried a first puff in the past.

FINDINGS

The logistic multi-level models indicated an association of family affluence with current weekly smoking [odds ratio (OR) = 1.088; 95% credible interval (CrI) = 1.055-1.121, P < 0.001], early smoking behaviour (OR = 1.066; CrI = 1.028-1.104, P < 0.001) and smoking among former experimenters (OR = 1.100; CrI = 1.071-1.130; P < 0.001). Gross domestic product (GDP) per capita was associated positively and significantly with the relationship between family affluence and current weekly smoking (OR = 1.005; CrI = 1.003-1.007; P < 0.001), early smoking behaviour (OR = 1.003; CrI = 1.000-1.005; P = 0.012) and smoking among former experimenters (OR = 1.004; CrI = 1.002-1.006; P < 0.001). The association of family affluence and smoking outcomes was significantly stronger for girls.

CONCLUSIONS

The difference in smoking prevalence between rich and poor is greater in more affluent countries.

Exploring the relationship between cigarette prices and smoking among adults: a cross-country study of low- and middle-income nations

INTRODUCTION

Evidence on the relationship between cigarette prices and adult smoking in low- and middle-income countries (LMICs) is relatively limited. This study offers new descriptive evidence on this relationship using data from a set of 13 LMICs.

METHODS

We use Global Adult Tobacco Survey (GATS) cross-country data from approximately 200,000 participants aged 15 and older. Estimates on the relationship between prices and adult smoking were obtained from logit models of smoking participation and ordinary least squares models of conditional cigarette demand.

RESULTS

Higher prices were associated with lower demand across countries, in terms of both smoking prevalence and daily number of cigarettes smoked among smokers. Our estimates suggest that the total price elasticity of cigarette demand in LMICs is approximately -0.53. We find that higher socioeconomic status (SES), represented through wealth and education effects is associated with lower chance of smoking overall, but among existing smokers, it may be associated with a larger number of cigarettes smoked.

CONCLUSIONS

After controlling for a set of individual demographic and country characteristics, cigarette prices retain a significant role in shaping cigarette demand across LMICs. Because higher SES is associated with a reduced chance of smoking overall but also with increased daily consumption among current smokers, optimal tobacco tax policies in LMICs may face an added need to accommodate to shifting SES structures within the populations of these countries.

Socioeconomic inequality in the prevalence of smoking and smokeless tobacco use in India

BACKGROUND

Tobacco consumption has been identified as the single biggest cause of inequality in morbidity and mortality. Understanding pattern of socioeconomic equalities in tobacco consumption in India will help in designing targeted public health control measures.

MATERIALS AND METHODS

Nationally representative data from the India Global Adult Tobacco Survey (GATS) conducted in 2009-2010 was analyzed. The survey provided information on 69,030 respondents aged 15 years and above. Data were analyzed according to regions for estimating prevalence of current tobacco consumption (both smoking and smokeless) across wealth quintiles. Multiple logistic regression analysis predicted the impact of socioeconomic determinants on both forms of current tobacco consumption adjusting for other socio-demographic variables.

RESULTS

Trends of smoking and smokeless tobacco consumption across wealth quintiles were significant in different regions of India. Higher prevalence of smoking and smokeless tobacco consumption was observed in the medium wealth quintiles. Risk of tobacco consumption among the poorest compared to the richest quintile was 1.6 times higher for smoking and 3.1 times higher for smokeless forms. Declining odds ratios of both forms of tobacco consumption with rising education were visible across regions. Poverty was a strong predictor in north and south Indian region for smoking and in all regions for smokeless tobacco use.

CONCLUSIONS

Poverty and poor education are strong risk factors for both forms of tobacco consumption in India. Public health policies, therefore, need to be targeted towards the poor and uneducated.

Effectiveness of individual and group counseling for cessation of tobacco habit amongst industrial workers in pimpri, pune--an interventional study

BACKGROUND

In India, tobacco consumption is responsible for one of the highest rates of oral cancer in the world, the annual oral cancer incidence is steadily increasing among young tobacco users. Studies have documented efforts taken by physicians, doctors and even dentists, in the form of individual or group counseling to curb tobacco use in smoke or smokeless form. However, which one is more effective, still remains an unanswered question. The aim of the study was to compare the effectiveness of individual and group counseling for cessation of the tobacco habit amongst industrial workers in Pune and to compare quit rates.

MATERIALS AND METHODS

An interventional study design was selected for 150 industrial workers which were stratified randomly into three groups (control, individual and group counseling groups) and interventions were provided to individual and group counseling groups over a period of six months, which were then compared with the control group that received brief intervention at the start of the study.

RESULTS

There was significant difference in the quit rates of the participants in the individual counseling group (ICG) and group counseling group (GCG) when compared at 6 months with the control counseling group (CCG). In the individual counseling group was 6% while in group counseling group it was 7.5% after six months of counseling.

CONCLUSIONS

No conclusion could be drawn whether individual or group counseling were better interms of quit rates. Individual and group counseling groups were definitely better than the control group when compared at 3 and 6 months, respectively.

Sex-stratified and age-adjusted social gradients in tobacco in Argentina and Uruguay: evidence from the Global Adult Tobacco Survey (GATS)

OBJECTIVE

To examine social gradients in tobacco use in Argentina and Uruguay, using newly available directly comparable data sets.

METHODS

Secondary analysis of Global Adult Tobacco Survey data from Argentina (N=6645) and Uruguay (N=5581). Social gradients in current tobacco use, exposure to secondhand smoke, and cessation attempt were examined with sex-stratified and age-adjusted logistic regression.

RESULTS

Among men, there is evidence of higher odds of being a current smoker among respondents with lower levels of education, but the association is only statistically significant for respondents with less than primary education in Uruguay (OR=2.15, 95% CI 1.22 to 3.77). Similarly, women with lower levels of education have higher odds of being a current smoker in Uruguay. The association between education and exposure to secondhand smoke is broadly similar for both sexes in both countries, with generally higher odds among groups with low education, though the relationship is only statistically significant among men in Uruguay (OR=1.77, 95% CI 1.08 to 2.92). In both countries, respondents with lower levels of education in general have higher odds of having attempted to quit smoking in the past year, although these associations did not attain statistical significance.

CONCLUSIONS

Social gradients in tobacco use, exposure to secondhand smoke and cessation attempts are broadly similar in both countries. Efforts to evaluate the long-term effects of tobacco control efforts in these countries should monitor how policies affect national averages, and the social gradients that are embedded in aggregate data.

Gender differences in the prevalence and determinants of tobacco use among school-aged adolescents (11-17 years) in Sudan and South Sudan

INTRODUCTION

Tobacco use is one of the leading and preventable causes of global morbidities and premature mortalities. The study explores gender differences in the prevalence and determinants of tobacco use among school-aged adolescents (11-17 years) in Sudan and South Sudan.

METHODS

The study utilized the national Global Youth Tobacco Survey (GYTS) data collected in 2005 for Sudan (4,277 unweighted; 131,631 weighted). Univariate and bivariate analyses were conducted to examine the associations between the dependent (tobacco use status) and independent variables. Logistic regression analyses were performed to identify the key factors which influence tobacco consumption among adolescents in the 2 Sudans for ever cigarette users, current cigarette users, and users of noncigarette tobacco products.

RESULTS

There were significant gender differences in the prevalence of ever cigarette users (21.8%; male=13.1%, female=6.5%, p<0.05) and current cigarette users (6.9%; male=4.9%, female = 1.3%, p<0.05) but not among users of noncigarette tobacco products (14.7%; male=6.8%, female=6.1%). Adolescent tobacco use was significantly associated with availability of monthly income or allowance, exposure to tobacco industry promotions, and tobacco-use behavior of familial relations. Knowledge about the harmful effects of secondhand smoke was related with decreased likelihood of tobacco use.

CONCLUSION

School programs that focus on health messages alone may not work for the adolescent population. Legislations that ban all types of tobacco advertisements, promotions, and sponsorships among adolescents are needed in the 2 countries.

Should we adjust health education methodology to low-educated employees needs? Findings from Latvia, Poland, Slovenia and Spain

OBJECTIVES

The presented study explored health beliefs and experiences as well as health education needs of low-educated employees (LEEs) (incomplete primary, primary, lower secondary and basic vocational education) in comparison to those with higher education (secondary and tertiary education) in four European countries: Latvia, Poland, Slovenia and Spain. The main aim was to identify a specificity of low-educated employees (LEEs) by capturing their opinions, experiences, attitudes and needs concerning health education.

MATERIAL AND METHODS

The sample consisted of 1691 individuals with the status of an employee (approximately 400 respondents in each of 4 countries participating in the project). The respondents were aged 25-54 (both the control group and the target group consisted in 1/3 of the following age groups: 25-34, 35-44 and 45-54). The respondents were interviewed during the years 2009 and 2010 with a structured questionnaire concerning their health, health behaviours as well as educational needs concerning health education.

RESULTS

The study revealed substantial differences in the attitudes of people from this group concerning methodology of health education. LEEs prefer more competitions and campaigns and less written educational materials in comparison to those with higher education. Additionally, they more often perceive a fee, longer time, necessity to take part in a knowledge test and a concern that their health will be checked as factors that can discourage them from taking part in a health training. On the other hand, LEEs can by encouraged to take part in such a training by a media broadcast concerning the event, snacks or lottery during the training, or financial incentives.

CONCLUSIONS

The results of the study proved the need for specific health education guidelines to conduct health education for low-educated employees. These guidelines should take in account the sources of health education preferred by LEEs as well as the factors that can encourage/discourage their participation in trainings concerning health.

Socio-economic patterning of tobacco use in Indian states

BACKGROUND

Studies in India have identified marked variations in overall tobacco use between socio-economic groups. We examined whether associations between socio-economic status (SES) and tobacco use varied across individual Indian states by tobacco type.

METHODS

Cross-sectional survey of 100,855 households in 24 Indian states and Union Territories conducted in 2009-2010. Outcome measures were household tobacco consumption by type. Logistic and linear regression models were used to examine associations at the household level between education, income and use and volume of tobacco consumed.

RESULTS

Overall, 52% of households used any form of tobacco product; the predominant form was smokeless tobacco (22%), followed by bidi (17%) and cigarettes (4%). Increasing household income and higher education level were associated with a higher likelihood of cigarette use but a lower likelihood of bidi and smokeless tobacco use in some Indian states. Increasing household income was associated with higher volumes of cigarette and bidi use among consuming households; however, association between educational level and volume of tobacco consumption was inconsistent.

CONCLUSION

SES has a varying impact on different types of tobacco use in Indian states. Policy makers should consider socio-economic patterning of tobacco use when designing, implementing and evaluating tobacco control interventions in different states of India.

Socioeconomic inequalities in smoking in low and mid income countries: positive gradients among women?

BACKGROUND

In Southern Europe, smoking among older women was more prevalent among the high educated than the lower educated, we call this a positive gradient. This is dominant in the early stages of the smoking epidemic model, later replaced by a negative gradient. The aim of this study is to assess if a positive gradient in smoking can also be observed in low and middle income countries in other regions of the world.

METHODS

We used data of the World Health Survey from 49 countries and a total of 233,917 respondents. Multilevel logistic regression was used to model associations between individual level smoking and both individual level and country level determinants. We stratified results by education, occupation, sex and generation (younger vs. older than 45). Countries were grouped based on GDP and region.

RESULTS

In Eastern Europe and the Eastern Mediterranean, we observed a positive gradient in smoking among older women and a negative gradient among younger women. In Sub-Saharan Africa and Latin America no clear gradient was observed: inequalities were relatively small. In South-East Asia and East Asia a strong negative gradient was observed. Among men, no positive gradients were observed, and like women the strongest negative gradients were seen in South-East Asia and East Asia.

CONCLUSIONS

A positive socio-economic gradient in smoking was found among older women in two regions, but not among younger women. But contrary to predictions derived from the smoking epidemic model, from a worldwide perspective the positive gradients are the exception rather than the rule.

Trends in educational differences in adolescent daily smoking across Europe, 2002-10

BACKGROUND

Across Europe, tobacco use is more prevalent among secondary school students attending vocational tracks compared with students attending academic tracks. The purpose of the present study is to describe trends in social inequality in daily smoking among adolescents between 2002 and 2010 by addressing both absolute social inequality (prevalence difference between vocational and academic tracks) and relative social inequality (prevalence ratio) in seven European countries.

METHODS

Analyses were based on data from 15-year-olds who participated in the Health Behaviour in School-aged Children study in 2002, 2006 and 2010 in Belgium, Croatia, France, Germany, Hungary, Italy and The Netherlands (total N = 32 867).

RESULTS

Overall, daily smoking decreased between 2002 and 2010 in Belgium, France, Germany and The Netherlands, increased in Croatia and remained stable in Hungary and Italy. Considerable differences in daily smoking according to educational track existed in all countries. Absolute educational inequalities increased dramatically in Croatia and Italy, while relative inequalities showed a tendency to increase in all countries (significant in Belgium and The Netherlands).

CONCLUSIONS

Conclusions on social inequality in adolescent smoking may appear differently when described by absolute and relative measures. Especially the large increase in absolute educational inequalities in daily smoking in Croatia and Italy are worrisome and warrant attention from the public health domain. The findings underline the need for appropriate smoking policies and interventions in vocational schools across Europe.

Inequalities in non-communicable diseases and effective responses

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

Developing the evidence base for addressing inequalities and smoking in the United Kingdom

AIMS

Smoking is an increasing cause of health inequalities in high-income countries. This supplement describes pilot projects set up in England to develop and test pathways to ensure that disadvantaged groups, where smoking is frequently the norm, are reached, encouraged and supported to stop their tobacco use. Target groups were: smokers attending centres set up for highly deprived parents; smokers with serious and enduring mental illness; pregnant smokers; prisoners/other offenders who smoked; South Asian tobacco chewers; and recent quitters from 'routine and manual' occupational groups.

METHODS

Commonalities observed across the six projects are summarized, alongside recommendations for implementation.

RESULTS

A significant barrier to implementation was the lack of mandatory identification of tobacco users across primary, secondary and community health-care settings and routine use of expired air carbon monoxide monitoring, particularly for high-risk groups. Appropriate use of financial incentives and national guidance is probably necessary to achieve both this and the adoption of 'joined-up' tobacco dependence treatment pathways for these target groups. Further research is needed on the impact of 'opt out' pathways: while resulting in increased referral rates, success rates were lower. In general, smoking cessation service targets were a barrier to implementation. Flexibility and tailoring of interventions were required and most projects trained those already working in relevant settings, given their greater understanding of target groups. Mandatory training of all frontline health-care staff was deemed desirable.

CONCLUSIONS

Implementing the findings of these projects will require resources, for training, incentivizing health-care workers and further research. However, continuing with the status quo may result in sustained tobacco use health inequalities for the foreseeable future.