Cohort changes in educational disparities in smoking: France, Germany and the United States

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Partners in Health: Investigating Social Genetic Effects Among Married and Cohabiting Couples

Partners resemble each other in health behaviors and outcomes such as alcohol use, smoking, physical activity, and obesity. While this is consistent with social contagion theory suggesting partner influence, it is notoriously difficult to establish causality because of assortative mating and contextual confounding. We offer a novel approach to studying social contagion in health in long-term partnerships by combining genetic data of both partners in married/cohabiting couples with longitudinal data on their health behaviors and outcomes. We examine the influence of the partner's genetic predisposition for three health outcomes and behaviors (BMI, smoking, and drinking) among married/cohabiting couples. We use longitudinal data from the Health and Retirement Study and the English Longitudinal Study of Ageing with data on health outcomes and genotypes for both partners. Results show that changes over time in BMI, smoking, and drinking depend on the partner's genetic predispositions to these traits. These findings underline the importance of people's social surroundings for their health and highlight the potential of targeting health interventions at couples.

Widening educational inequalities in mortality in more recent birth cohorts: a study of 14 European countries

BACKGROUND

Studies of period changes in educational inequalities in mortality have shown important changes over time. It is unknown whether a birth cohort perspective paints the same picture. We compared changes in inequalities in mortality between a period and cohort perspective and explored mortality trends among low-educated and high-educated birth cohorts.

DATA AND METHODS

In 14 European countries, we collected and harmonised all-cause and cause-specific mortality data by education for adults aged 30-79 years in the period 1971-2015. Data reordered by birth cohort cover persons born between 1902 and 1976. Using direct standardisation, we calculated comparative mortality figures and resulting absolute and relative inequalities in mortality between low educated and high educated by birth cohort, sex and period.

RESULTS

Using a period perspective, absolute educational inequalities in mortality were generally stable or declining, and relative inequalities were mostly increasing. Using a cohort perspective, both absolute and relative inequalities increased in recent birth cohorts in several countries, especially among women. Mortality generally decreased across successive birth cohorts among the high educated, driven by mortality decreases from all causes, with the strongest reductions for cardiovascular disease mortality. Among the low educated, mortality stabilised or increased in cohorts born since the 1930s in particular for mortality from cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease and alcohol-related causes.

CONCLUSIONS

Trends in mortality inequalities by birth cohort are less favourable than by calendar period. In many European countries, trends among more recently born generations are worrying. If current trends among younger birth cohorts persist, educational inequalities in mortality may further widen.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S

INTRODUCTION

Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics.

METHODS

Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021.

RESULTS

Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group.

CONCLUSIONS

Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Who buys non-alcoholic beer in Finland? Sociodemographic characteristics and associations with regular beer purchases

BACKGROUND

The consumption of non-alcoholic beer and other non-alcoholic and low-alcohol beverages has grown significantly in recent years. Due to a lack of suitable datasets, there have been few studies conducted on the forerunners of the non-alcoholic beer consumption trend. This study examined the associations of sociodemographic characteristics with non-alcoholic beer purchase, and of non-alcoholic beer purchases with regular beer purchases.

METHODS

The data consisted of longitudinal individual purchases of non-alcoholic and regular beer from grocery stores in 2017 and 2018. The study participants were loyalty cardholders from the largest food retailer in Finland (n = 47,066). The level of education, household income and occupational status were analyzed as determinants of non-alcoholic beer purchase using logistic regression models. The changes in the regular and non-alcoholic beer purchases from 2017 to 2018 and the distributions of non-alcoholic beer purchase by regular beer purchase, by gender and by age were described.

RESULTS

Between 2017 and 2018, the total volume of non-alcoholic beer purchases increased from 2.3% to 3.7% of the total volume of all beer purchases. Men and older people purchased non-alcoholic beer more often than women and younger people did. Non-alcoholic beer purchases were most common among the highly educated and high-income consumers. Non-alcoholic beer purchases were most prevalent in the groups with the highest volumes of regular beer purchase.

CONCLUSIONS

Educated and affluent consumers have been the forerunners of non-alcoholic beer consumption in Finland. In order to promote the substitution of regular beer with non-alcoholic beer the shift towards lower-strength beverages should be facilitated across social strata.

Beliefs about harms of cigarette smoking among Norwegian adults born from 1899 to 1969. Do variations across education, smoking status and sex mirror the decline in smoking?

Background and aim

Smoking is one of the most important causes of socioeconomic disparities in morbidity and mortality. The aim of this study was to examine if beliefs about harms of smoking differed across gender, smoking status and education among Norwegian adults born between 1899 and 1969.

Methods

Using data from a nationally representative survey of smoking habits and a multinomial logit/negative binomial two-stage hurdle model design, we examined (first hurdle) the associations between birth cohort, gender, education and smoking status and four beliefs about cigarette smoking: i) smoking is not harmful, ii) do not know if smoking is harmful, iii) any number of cigarettes per day (CPD) is harmful and iv) smoking more than a given nonzero number of CPD is harmful, and (second hurdle) the predicted number of CPD that could be smoked without causing harm (from outcome iv).

Results

The probability of believing that smoking was not harmful was close to zero, regardless of birth cohort, sex, education and smoking status. The probability of not knowing if smoking was harmful decreased from around 0.7 to almost zero across cohorts. The probability of believing that smoking more than zero CPD was harmful increased from less than 0.1 to around 0.7, while the probability of believing that there is some safe level of smoking increased with cohorts born from 1900 to 1930 before declining. Respondents with primary/secondary education consistently believed smoking to be less harmful compared to respondents with tertiary education, but cohort trajectories were similar.

Discussion

The similar birth cohort trajectories in beliefs about the harms of smoking do not support the idea that Norwegian adults with lower education has had qualitatively different beliefs about the harmfulness of smoking compared to those with higher education. The persistent and large socioeconomic gradient is likely a result of other factors.

Diverging Trends and Expanding Educational Gaps in Smoking in China

Introduction: The male smoking rate in China declined moderately through the 1990s and early 2000s, but the decline has since stagnated. It is unclear why the decline stalled and whether it stalled uniformly across all social strata. Theories that view socioeconomic status as a fundamental cause of health predict that socioeconomic gaps in smoking may widen, but theories emphasizing the cultural context of health behavior cast doubt on the prediction. We investigated changes in the socioeconomic gaps in smoking during recent decades in China. Methods: We applied growth-curve models to examine inter- and intra-cohort changes in socioeconomic gaps in male smoking in China using data from a national longitudinal survey spanning 25 years. Results: We found diverging trends in smoking in men with different education levels among the post-1980 cohorts; for high-education men, smoking participation consistently declined, but for low-education men, the decline stopped and possibly reversed. The stagnation in the decline in overall smoking rate since 2010 was mostly due to the stalling of the decline of smoking among low-education men in the most recent cohorts. The diverging trends were a continuation of a general trend in expanding educational gaps in smoking that emerged in the cohorts born after 1960. Our analysis also identified widening educational gaps over age within each cohort. Conclusion: We identified a long-term widening in educational gaps in smoking in China. An effective way to reduce smoking, social inequality in smoking and possibly health disparities in China is to target the smoking behavior of vulnerable groups.

Time Trends and Income Inequalities in Cancer Incidence and Cancer-Free Life Expectancy - a Cancer Site-Specific Analysis of German Health Insurance Data

Cancer represents a major burden of morbidity and mortality globally. So far, however, little is known on time trends and inequalities in the lengths of life spent free of any cancer. This study steps into this gap by analyzing time trends and income inequalities in cancer-free life expectancy (CFLE). For this retrospective cohort study, data of a large German health insurer were used (N = 3,405,673individuals, 2006-2018). Income inequalities were assessed using individual income (<60% of German average income (GAI) and ≥60% of GAI). Trends in incidence risks were analysed employing proportional-hazard regression models by splitting the observation time into three periods of 52 months. Trends in CFLE in total and for the most common site-specific cancers were calculated based on multiple decrement life tables. Incidence rates declined in almost all cancers and CFLE increased substantially over time (49.1 (95% CI 48.8-49.4) to 51.9 (95% CI 51.6-52.2) years for men, 53.1 (95% CI 52.7-53.5) to 55.4 (95% CI 55.1-55.8) years for women at age 20 for total cancer) and income groups. Considerable income inequalities in cancer risks were evident in both sexes, but were more pronounced in men (total cancer HR 0.86 (95% CI 0.85-0.87)), with higher-income individuals having lower risks. The highest income inequalities were found in colon (HR 0.90 (95% CI 0.87-0.93)), stomach (HR 0.78 (95% CI 0.73-0.84)), and lung cancer (HR 0.58 (95% CI 0.56-0.60)) in men. A reverse gradient was found for skin (HR 1.39 (95% CI 1.30-1.47) men; HR 1.27 (95% CI 1.20-1.35) women) and prostate cancer (HR 1.13 (95% CI 1.11-1.15)). The proportion of CFLE in total life expectancy declined for lung, skin and cervical cancer in women, indicating a relative shortening of lifetime spent cancer-free. In contrast, increasing proportions were found in breast and prostate cancer. To our knowledge, this is the first study analysing trends and income inequalities in CFLE. The life span free of cancer increased clearly over time. However, not all cancer types contributed equally to this positive development. Income inequalities persisted or tended to widen, which underlines the need for increased public health efforts in socioeconomically vulnerable groups.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

•

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

•

Differences in smoking across transition milestones differed by gender.

•

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

Leading cancers contributing to educational disparities in cancer mortality in the US, 2017

Purpose

To inform prevention efforts, we sought to determine which cancer types contribute the most to cancer mortality disparities by individual-level education using national death certificate data for 2017.

Methods

Information on all US deaths occurring in 2017 among 25–84-year-olds was ascertained from national death certificate data, which include cause of death and educational attainment. Education was classified as high school or less (≤ 12 years), some college or diploma (13–15 years), and Bachelor's degree or higher (≥ 16 years). Cancer mortality rate differences (RD) were calculated by subtracting age-adjusted mortality rates (AMR) among those with ≥ 16 years of education from AMR among those with ≤ 12 years.

Results

The cancer mortality rate difference between those with a Bachelor's degree or more vs. high school or less education was 72 deaths per 100,000 person-years. Lung cancer deaths account for over half (53%) of the RD for cancer mortality by education in the US.

Conclusion

Efforts to reduce smoking, particularly among persons with less education, would contribute substantially to reducing educational disparities in lung cancer and overall cancer mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01471-9.

Parental income gradients in adult health: a national cohort study

BACKGROUND

Disparities in health by adult income are well documented, but we know less about the childhood origins of health inequalities, and it remains unclear how the shape of the gradient varies across health conditions. This study examined the association between parental income in childhood and several measures of morbidity in adulthood.

METHODS

We used administrative data on seven complete Norwegian birth cohorts born in 1967-1973 (N = 429,886) to estimate the association between parental income from birth to age 18, obtained from tax records available from 1967, linked with administrative registries on health. Health measures, observed between ages 39 and 43, were taken from registry data on consultations at primary health care services based on diagnostic codes from the International Classification of Primary Care (ICPC-2) and hospitalizations and outpatient specialist consultations registered in the National Patient Registry (ICD-10).

RESULTS

Low parental income during childhood was associated with a higher risk of being diagnosed with several chronic and pain-related disorders, as well as hospitalization, but not overall primary health care use. Absolute differences were largest for disorders related to musculoskeletal pain, injuries, and depression (7-9 percentage point difference). There were also differences for chronic disorders such as hypertension (8%, CI 7.9-8.5 versus 4%, CI 4.1-4.7) and diabetes (3.2%, CI 3.0-3.4 versus 1.4%, CI 1.2-1.6). There was no difference in consultations related to respiratory disorders (20.9%, CI 20.4-21.5 versus 19.7%, CI 19.2-20.3). Childhood characteristics (parental education, low birth weight, and parental marital status) and own adult characteristics (education and income) explained a large share of the association.

CONCLUSIONS

Children growing up at the bottom of the parental income distribution, compared to children in the top of the income distribution, had a two- to threefold increase in somatic and psychological disorders measured in adulthood. This shows that health inequalities by socioeconomic family background persist in a Scandinavian welfare-state context with universal access to health care.

Increasing socioeconomic disparities in tobacco smoking decline among French adolescents (2000-2017)

BACKGROUND

This paper studies the evolution of transitions from first cigarette use to daily use by socioeconomic status (SES) among French adolescents over the course of 17 years, in a context of decreasing prevalence of tobacco use.

METHODS

A total of 182 266 adolescents participated in the nationally representative ESCAPAD survey at nine different time points between 2000 and 2017. Discrete time-event analysis was used to model the transition to daily cigarette use as a function of SES, gender, age at onset and the use of other psychoactive substances.

RESULTS

Although lifetime cigarette smoking and daily cigarette smoking decreased significantly over the studied time span, suggesting a positive impact of prevention policies, disadvantaged adolescents were consistently more prone to engage in daily cigarette smoking, more so in 2017 than 15 years earlier. In the same time span, transitions from initiation to daily cigarette smoking have shortened, with an accelerated pace among underprivileged adolescents.

CONCLUSIONS

Accelerated transitions from initiation to daily cigarette use are a prevalent trend among disadvantaged adolescents in France. Efforts to mitigate the impact of marketing strategies and to promote health literacy should be pursued to reduce social inequalities in health.

Experimenting first with e-cigarettes versus first with cigarettes and transition to daily cigarette use among adolescents: the crucial effect of age at first experiment

BACKGROUND AND AIMS

Most studies in English-speaking countries have found a positive association between e-cigarette experimentation and subsequent daily tobacco smoking among adolescents. However, this result may not be valid in other cultural contexts; in addition, few studies have assessed whether this association varies with the subject' age at the time of e-cigarette experimentation. This study aimed to estimate the association between experimenting first with e-cigarette (rather than tobacco) and subsequent daily smoking according to age at the time of experimentation.

DESIGN

Secondary analysis; risk ratios (RRs) computed using modified Poisson regressions with inverse probability weighting.

SETTING

A cross-sectional nation-wide representative survey performed in 2017 in France.

PARTICIPANTS

French adolescents (n = 24 111), aged 17 to 18.5 years, who had previously experimented with either e-cigarettes or tobacco.

MEASURES

Exposure was defined as the experimentation with e-cigarettes first (whether or not followed by experimentation with tobacco); the outcome as daily tobacco smoking at the time of data collection. Gender, age, literacy, socio-economic status, pre-exposure repeat school years and experimentation with drunkeness, 3 licit and 8 illicit drugs were adjusted for. Uncertainties about the sequence of events defining exposure were handled by the definition of three patterns of exposure, to avoid a misclassification bias.

FINDINGS

Exposure reduced the risk of transition to daily smoking: RR = 0.58, 95% confidence interval (CI) = 0.54, 0.62. This effect increased in a linear manner with age at exposure (RR = 0.87, 95% CI = 0.78; 0.98 for 1 year, P < 0.001): from RR = 1.30, 95% CI = 1.09; 1.54 at age 9 to RR = 0.38, 95% CI = 0.32; 0.45 at age 17.

CONCLUSIONS

Experimenting with e-cigarettes first (as opposed to tobacco first) appears to be associated with a reduction in the risk of daily tobacco smoking among French adolescents aged 17-18.5, but this risk varies negatively with age at experimentation, and early e-cigarette experimenters are at higher risk.

Birth-cohort estimates of smoking initiation and prevalence in 20th century Australia: Synthesis of data from 33 surveys and 385,810 participants

The aim of our study was to quantify sex-specific patterns of smoking prevalence and initiation in 10-year birth cohorts from 1910 to 1989 in Australia. We combined individual data of 385,810 participants from 33 cross-sectional surveys conducted between 1962 and 2018. We found that age-specific smoking prevalence varied considerably between men and women within birth cohorts born before 1960. The largest difference was observed in the earliest cohort (1910-1919), with up to 37.7% point greater proportion of current smokers in men than in women. In subsequent cohorts, the proportion decreased among men, but increased among women, until there was no more than 7.4% point difference in the 1960-69 birth cohort. In the 1970-79 and 1980-89 cohorts, smoking among men marginally increased, but the proportion was at most ~11.0% points higher than women. Our analysis of initiation indicated that many women born before the 1930s who smoked commenced smoking after age 25 years (e.g., ~27% born in 1910-19); compared to at most 8% of men in any birth cohort. The earliest birth cohort (1910-1919) had the greatest difference in age at initiation between sexes; 26.6 years in women versus 19.0 in men. In later cohorts, male and female smokers initiated increasingly earlier, converging in the 1960-69 cohort (17.6 and 17.8 years, respectively). While 22.9% of men and 8.4% of women initiated smoking aged < = 15 in the 1910-1919 cohort, in the latest cohort (1980-89) the reverse was true (21.4% and 28.8% for men and women, respectively). Marked differences in smoking prevalence and age at initiation existed between birth cohorts of Australian men and women born before 1960; after this, sex-specific trends in prevalence and initiation were similar. Understanding these patterns may inform the evaluation of tobacco control policies and the targeting of potential interventions for exposed populations such as lung cancer screening.

Socioeconomic inequalities in lung cancer - a time trend analysis with German health insurance data

BACKGROUND

Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany.

METHODS

The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006-2009, 2010-2013 and 2014-2017.

RESULTS

Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position.

CONCLUSION

The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

Characterization of cannabis use by patients with myotonic dystrophy type 1: A pilot study

The treatment of myotonic dystrophy type 1 (DM1) focuses on reducing symptom burden. However, since medication often fails to produce satisfying symptom relief, some patients seek alternatives, such as cannabis, to help reduce some of these symptoms. The aim of this study was to provide an accurate profile of cannabis use among DM1 patients. Phone interviews were conducted to identify current and former users, and to assess reasons for cannabis use. Characteristics of cannabis use were also investigated. Briefly, among the 72 study participants, 22.2% currently used cannabis and a majority of them (56.9%) reported using it to relieve symptoms associated with DM1. These users, classified as therapeutic users, reported poorer health status (EQ-5D index scores: 0.532±0.230 vs. 0.823±0.208, p = 0.020; EQ-VAS scale 50.56±10.74 vs. 75.57±21.50, p = 0.009) than non-therapeutic users. Finally, differences among sex were also highlighted. While the therapeutic effects of cannabis were not explored in our study, our results support the potential role of cannabis and cannabinoids in the treatment of DM1-associated symptoms which will need to be thoroughly investigated.

Compression, expansion, or maybe both? Growing inequalities in lung cancer in Germany

BACKGROUND

Lung Cancer (LC) is one of the most common malign diseases worldwide. So far, it is unclear if the development of LC incidence and mortality leads to morbidity compression or expansion and whether these developments differ by socioeconomic characteristics. This study analyses time trends in social and gender inequalities in life years with and without LC in Germany.

METHODS

The study is based on data of a large German statutory health insurance provider (N = 2,511,790). Incidence and mortality risks were estimated from multistate survival models. Trends in life years with and without LC were analysed using multistate life table analyses. All analyses were performed separately for gender, time period (2006-2009 and 2014-2017), and income group (<60% and ≥60% of the German average income).

RESULTS

Among men, declining LC incidence rates resulted in gains of life years free of LC and declining LC- affected life years and led to a relative compression, which was strongest in men with higher incomes. Among women, a clear increase in life years with LC led to an expansion of the lifespan affected by LC. This expansion was mainly driven by increasing incidence rates in women with low incomes. Overall, income inequalities in LC increased in both genders.

CONCLUSIONS

Our analyses reveal that developments in the length of life affected by LC differed substantially by gender and income and led to widening health inequalities over time. Public health efforts should mainly focus on vulnerable groups to reduce the persisting social inequalities in LC.

Relative and absolute socioeconomic inequality in smoking: time trends in Germany from 1995 to 2013

PURPOSE

This study aimed to investigate time trends in relative and absolute socioeconomic inequality in smoking prevalence in Germany using several indicators for socioeconomic position.

METHODS

We conducted a repeated cross-sectional study using representative samples of the German population aged between 25 and 64 years in 1995, 1999, 2005, 2009, and 2013 (n = 857,264). Socioeconomic position was measured by indicators for income, education, and occupation. Relative and absolute socioeconomic inequalities were estimated with the regression-based relative index of inequality and the slope index of inequality, respectively. Trends in inequalities were estimated with interaction terms for time and relative index of inequality/slope index of inequality.

RESULTS

Highest and increasing smoking prevalence was observed among long-term unemployed and people with less than 60% of the median household income. Between 1995 and 2013, relative increases in inequalities in smoking prevalence ranged from 31% (95% confidence interval, 26%-36%; men, occupation) to 94% (95% confidence interval, 84%-104%; women, education). Absolute increases ranged from 6.2 (95% confidence interval, 4.7-7.6) percentage points (men, occupation) to 20.3 (95% confidence interval, 18.9-21.7) percentage points (women, education).

CONCLUSIONS

Relative and absolute socioeconomic inequalities in smoking prevalence increased in Germany between 1995 and 2013, with regard to income, education, and occupation, particularly among women.

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

Background

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

Methods

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

Results

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

Conclusions

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

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset—i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Evaluating the Impact of the Synar Program: Tobacco Access and Use among Youth in Mississippi, the South, and the U.S

(1) Background: This study examines the impact of Synar policy adoption on youth commercial access to tobacco products in Mississippi, the South, and the remaining U.S. The principal focus on youth commercial access is complemented by analyses of Synar's impact on minors' non-commercial access to tobacco and tobacco use patterns. Mississippi has been especially aggressive in implementing Synar, as evidenced by its unusually low retailer violation rates (RVRs). Synar, a mandatory, enforceable regulation meant to limit youth's retail access to tobacco, was implemented nationwide in 1997. This study is governed by a combination of conceptual insights from a diffusion of health innovation perspective and structuration theory. (2) Methods: Repeated cross-sectional data from 1995 to 2011 from the CDC Youth Risk Behavior Survey are analyzed using a pre/post-implementation, quasi-experimental analytic strategy. Tobacco access and use in the pre-Synar era (1995-1997) are compared with two post-Synar periods (1999-2005 and 2007-2011), thereby highlighting diffusion effects related to this policy innovation within Mississippi, the South, and the remaining U.S. (3) Results: Analyses of temporal trends reveal that Mississippi and other study regions effectively restricted commercial access to tobacco. Positive outcomes associated with Synar adoption were observed several years after initial implementation, thus supporting a diffusion of innovation perspective. However, results also reveal that Mississippi youth were more inclined than their counterparts elsewhere to gain access to tobacco through non-commercial means after Synar implementation, and that declines in tobacco use among Mississippi youth were less robust than those observed elsewhere. Such variegated effects are in line with expectations linked to structuration theory. (4) Conclusions: Synar policy implementation has been generally effective at deterring youth access to tobacco and, in many cases, has yielded declines in tobacco use. However, there is no evidence that especially aggressive retailer compliance checks in Mississippi have yielded distinctive benefits for youth in this state.

Association between educational level and total and cause-specific mortality: a pooled analysis of over 694 000 individuals in the Asia Cohort Consortium

OBJECTIVE

To study the association of educational level and risk of death from all causes, cardiovascular disease (CVD) and cancer among Asian populations.

DESIGN

A pooled analysis of 15 population-based cohort studies.

SETTING AND PARTICIPANTS

694 434 Asian individuals from 15 prospective cohorts within the Asia Cohort Consortium.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

HRs and 95% CIs for all-cause mortality, as well as for CVD-specific mortality and cancer-specific mortality.

RESULTS

A total of 694 434 participants (mean age at baseline=53.2 years) were included in the analysis. During a mean follow-up period of 12.5 years, 103 023 deaths were observed, among which 33 939 were due to cancer and 34 645 were due to CVD. Higher educational levels were significantly associated with lower risk of death from all causes compared with a low educational level (≤primary education); HRs and 95% CIs for secondary education, trade/technical education and ≥university education were 0.88 (0.85 to 0.92), 0.81 (0.73 to 0.90) and 0.71 (0.63 to 0.80), respectively (ptrend=0.002). Similarly, HRs (95% CIs) were 0.93 (0.89 to 0.97), 0.86 (0.78 to 0.94) and 0.81 (0.73 to 0.89) for cancer death, and 0.88 (0.83 to 0.93), 0.77 (0.66 to 0.91) and 0.67 (0.58 to 0.77) for CVD death with increasing levels of education (both ptrend <0.01). The pattern of the association among East Asians and South Asians was similar compared with ≤primary education; HR (95% CI) for all-cause mortality associated with ≥university education was 0.72 (0.63 to 0.81) among 539 724 East Asians (Chinese, Japanese and Korean) and 0.61 (0.54 to 0.69) among 154 710 South Asians (Indians and Bangladeshis).

CONCLUSION

Higher educational level was associated with substantially lower risk of death among Asian populations.

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

Introduction

Since the early 2000s, several tobacco control policies have been implemented in Germany. Current research is inconsistent about how strengthening tobacco control can affect social inequalities in smoking. This study examines whether educational inequalities in adult smoking have widened in Germany since 2003.

Methods

Data were used from four cross-sectional national health surveys conducted between 2003 and 2012 (n = 54,197; age = 25-69 years). Participants who smoked daily or occasionally were classified as smokers. The regression-based Slope Index of Inequality and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in smoking, respectively.

Results

In each survey year, smoking was associated with lower education. Overall, crude and age-standardized smoking rates declined over time. Stratified by education, trends of declining smoking rates were observed only in the high and medium education groups, whereas no statistically significant trend was found in the low education group. Relative educational inequalities in smoking increased significantly in men (2003: RII=1.74, 95% confidence interval 1.46 to 2.07; 2012: RII = 2.25, 95% confidence interval 1.90 to 2.67; p-trend = .019). Absolute educational inequalities in smoking were not found to have changed significantly during the study period.

Conclusions

In the course of declining smoking rates, educational inequalities in smoking persisted in both absolute and relative terms. In men, relative inequalities in smoking may even have widened within only 9 years. Tobacco control policies should not only be targeted at the entire population but also attempt to reduce social inequalities in smoking by focusing more on socially disadvantaged groups.

Implications

Smoking is associated with lower education in most European countries and contributes to social inequalities in health. Since the beginning of the 2000s, Germany has implemented a variety of tobacco control policies to reduce smoking in the population. This study reveals that despite a general decline in adult smoking, educational inequalities in smoking have persisted and even widened in Germany since 2003. The findings emphasize that more targeted efforts are needed to tackle smoking-induced inequalities in health.

What drives us apart? Decomposing intersectional inequalities in cigarette smoking by education and sexual orientation among U.S. adults

Background

Socio-economic and sexual orientation inequalities in cigarette smoking are well-documented; however, there is a lack of research examining the social processes driving these complex inequalities. Using an intersectional framework, the current study examines key processes contributing to inequalities in smoking between four intersectional groups by education and sexual orientation.

Methods

The sample (28,362 adults) was obtained from Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Four intersectional positions were created by education (high- and low-education) and sexual orientation (heterosexual or lesbian, gay, bisexual, or queer/questioning (LGBQ). The joint inequality, the referent socio-economic inequality, and the referent sexual orientation inequality in smoking were decomposed by demographic, material, tobacco marketing-related, and psychosocial factors using non-linear Oaxaca decomposition.

Results

Material conditions made the largest contribution to the joint inequality (9.8 percentage points (p.p.), 140.9%), referent socio-economic inequality (10.01 p.p., 128.4%), and referent sexual orientation inequality (4.91 p.p., 59.8%), driven by annual household income. Psychosocial factors made the second largest contributions to the joint inequality (2.12 p.p., 30.3%), referent socio-economic inequality (2.23 p.p., 28.9%), and referent sexual orientation inequality (1.68 p.p., 20.5%). Referent sexual orientation inequality was also explained by marital status (20.3%) and targeted tobacco marketing (11.3%).

Conclusion

The study highlights the pervasive role of material conditions in inequalities in cigarette smoking across multiple dimensions of advantage and disadvantage. This points to the importance of addressing material disadvantage to reduce combined socioeconomic and sexual orientation inequalities in cigarette smoking.

[Trends in educational inequalities in smoking among adolescents in Germany : Evidence from four population-based studies]

BACKGROUND

In Germany, smoking prevalence among adolescents has significantly declined since the early 2000s. However, data show that adolescent smoking rates considerably differ between different types of secondary schools. The aim of our study was to examine how educational inequalities in adolescent smoking behaviour have developed over time.

METHODS

Data were used from four population-based studies (each consisting of repeated cross-sectional surveys from 2001-2015): the representative surveys of the Federal Centre for Health Education, the German Health Interview and Examination Survey for Children and Adolescents, the Health Behaviour in School-aged Children Study, and the European School Survey Project on Alcohol and Other Drugs. Each study comprised different age groups (within the age range of 11-17 years) and used different smoking measures. Adolescents' educational status was based on the attended type of secondary school. Absolute and relative educational inequalities were presented as prevalence differences and prevalence ratios, respectively.

RESULTS

Despite methodical differences, all four studies similarly reveal that adolescent smoking rates have significantly declined in all educational groups. However, lower smoking rates among secondary school students attending higher educational tracks could be observed. While absolute educational inequalities tended to decrease over time, relative inequalities between educational groups remained rather stable or even increased.

DISCUSSION

Declining adolescent smoking rates suggest that smoking may have lost some of its attractiveness for young people. Our findings further emphasize the importance of tobacco control measures such as raising cigarette taxes, smoking bans, and increasing minimum legal age for tobacco purchase. As relative educational inequalities in adolescent smoking rates did not diminish over time, setting- and target group-specific interventions should focus more on students in middle and lower secondary school tracks.

"Under the Skin" and into the Gut: Social Epidemiology of the Microbiome

PURPOSE OF THE REVIEW

As the science of the microbiome advances, social epidemiologists can contribute to understanding how the broader social environment shapes the microbiome over the life course. This review summarizes current research and describes potential mechanisms of the social epidemiology of the microbiome.

RECENT FINDINGS

Most existing literature linking the social environment and the microbiome comes from animal models, focused on the impact of social interactions and psychosocial stress. Suggestive evidence of the importance of early life exposures, health behaviors, and the built environment also point to the importance of the social environment for the microbiome in humans.

SUMMARY

Social epidemiology as a field is well poised to contribute expertise in theory and measurement of the broader social environment to this new area, and to consider both the upstream and downstream mechanisms by which this environment gets "under the skin" and "into the gut." As population-level microbiome data becomes increasingly available, we encourage investigation of the multi-level determinants of the microbiome and how the microbiome may link the social environment and health.

Education, Smoking, and Cohort Change: Forwarding a Multidimensional Theory of the Environmental Moderation of Genetic Effects

We introduce a genetic correlation by environment interaction model [(rG)xE] which allows for social environmental moderation of the genetic relationship between two traits. To empirically demonstrate the significance of the (rG)xE perspective, we use genome wide information from respondents of the Health and Retirement Study (HRS; n = 8,181; birth years 1920-1959) and the National Longitudinal Study of Adolescent to Adult Health (Add Health; n = 4,347; birth years 1974-1983) to examine whether the genetic correlation (rG) between education and smoking has increased over historical time. Genetic correlation estimates (rG_HRS = -0.357; rG_{Add Health} = -0.729) support this hypothesis. Using polygenic scores for educational attainment, we show that this is not due to latent indicators of intellectual capacity, and we highlight the importance of education itself as an explanation of the increasing genetic correlation. Analyses based on contextual variation the milieus of the Add Health respondents corroborate key elements of the birth cohort analyses. We argue that the increasing overlap with respect to genes associated with educational attainment and smoking is a fundamentally social process involving complex process of selection based on observable behaviors that may be linked to genotype.

Anti-smoking policy in Russia: Relevant factors and program planning

In this paper, we consider anti-smoking policy in Russia and the socioeconomic factors that influence an individual's decision to smoke. Among various factors, we investigate the individual time preferences of Russians. To estimate individual time preferences, we use an experiment in which survey respondents are given hypothetical money prizes. We find that being middle-aged, being unmarried and having parents who smoke are positively correlated with both men and women's likelihood of taking up smoking in Russia. We consider the possible endogeneity of an individual's health status and find a positive relationship between smoking and the time preferences of Russians. Our findings confirm that decisionmakers should devote their efforts primarily to developing restrictive anti-smoking policy. The choice of policy measures should be guided by the individual characteristics of target population groups. Social advertising, public lectures and preventive care should be actively engaged in forming public attitudes towards smoking.

Education and Health across Lives and Cohorts: A Study of Cumulative (Dis)advantage and Its Rising Importance in Germany

Research from the United States has supported two hypotheses. First, educational gaps in health widen with age-the cumulative (dis)advantage hypothesis. Second, this relationship has intensified across cohorts-the rising importance hypothesis. In this article, we used 23 waves of panel data (Socio-Economic Panel Study, 1992-2014) to examine both hypotheses in the German context. We considered individual and contextual influences on the association between education and health, and we assessed gender differences in health trajectories over the life course (ages 23 to 84) and across cohorts (born between 1930 and 1969). For women, we found no support for either hypothesis, as educational gaps in self-rated health remained stable with age and across cohorts. Among men, we found support for both hypotheses, as educational gaps in self-rated health widened with age and increasingly in newer cohorts.

Socioeconomic differences in smoking in Jordan, Lebanon, Syria, and Palestine: A cross-sectional analysis of national surveys

Introduction

The association between education and wealth, as fundamental determinants of health, and smoking is well-established. Yet, social inequalities have received little attention in the expanding field of tobacco research in the Arab region. In this study, we examine inequalities in cigarette smoking by education and wealth in four Arab countries.

Methods

Utilizing the most recently available population-level data sets (Syria 2009 PAPFAM, Jordan 2012 DHS, Palestine 2010 Family Health Survey, and Lebanon 2004 PAPFAM), we tested the association between cigarette smoking and education and wealth–controlling for age, marital status, and region of residence–for each country, and among men and women depending on data availability.

Results

Cigarette smoking prevalence among Arab men is high– 51.3% in Syria, 39.7% in Palestine, and 42.1% in Lebanon; among women, prevalence is 8.4% in Syria, 10.9% in Jordan, and 24.3% Lebanon. Cigarette smoking shows the expected patterns inequalities by education among men in Syria, Palestine, and Lebanon, and among women in Jordan and Lebanon. On the other hand, wealth does not show a clear pattern in its association with cigarette smoking and, in some cases (men in Palestine and women in Syria) the behavioral risk is higher among the wealthiest.

Conclusions

Available data from 2004–2012 show that cigarette smoking among men and women in the four Arab countries is predominant among those with limited access to education as a fundamental cause. The weak or absent negative association between wealth and cigarette smoking suggests that access to material resources does not precipitate a reduction in the consumption of tobacco.

Factores socioeconómicos asociados con la compra ilegal de productos de tabaco en Panamá

Objetivo. Caracterizar la compra ilegal de productos derivados del tabaco y su asociación con variables socio­demográficas y socioeconómicas. Material y métodos. La fuente de datos es la Encuesta Mundial de Tabaco en Adultos de 2013. Se caracterizó la compra ilícita mediante variables sociodemográficas (SOD) y socioeconómicas (SES). Se utilizaron modelos de regresión logística. Resultados. Se encontraron asociaciones de las variables SOD y SES con compra ilegal, particularmente en hombres; grupo etario de 15 a 39 años, educación no formal, empleado de gobierno e inactivos, área urbana, fumador diario y en el primer quintil de ingresos. Conclusiones. Las variables SOD y SES influyen en la compra ilícita. Es importante la vigilancia del comercio ilícito en el segmento minorista y la aplicación efectiva de las normas vigentes.

Level of education and mortality after radical prostatectomy

Estimating the risk of competing mortality is of importance in men with early prostate cancer to choose the most appropriate way of management and to avoid over- or under-treatment. In this study, we investigated the impact of the level of education in this context. The study sample consisted of 2630 patients with complete data on level of education (college, university degree, master craftsmen, comparable profession, or others), histopathological tumor stage (organ confined or extracapsular), lymph node status (negative or positive), and prostatectomy specimen Gleason score (<7, 7, or 8–10) who underwent radical prostatectomy between 1992 and 2007. Overall, prostate cancer-specific, competing, and second cancer-related mortalities were study endpoints. Cox proportional hazard models for competing risks were used to study combined effects of the variables on these endpoints. A higher level of education was independently associated with decreased overall mortality after radical prostatectomy (hazard ratio [HR]: 0.75, 95% confidence interval [95% CI]: 0.62–0.91, P = 0.0037). The mortality difference was attributable to decreased second cancer mortality (HR: 0.59, 95% CI: 0.40–0.85, P = 0.0052) and noncancer mortality (HR: 0.73, 95% CI: 0.55–0.98, P = 0.0345) but not to differences in prostate cancer-specific mortality (HR: 1.16, 95% CI: 0.79–1.69, P = 0.4536 in the full model). In conclusion, the level of education might serve as an independent prognostic parameter supplementary to age, comorbidity, and smoking status to estimate the risk of competing mortality and to choose optimal treatment for men with early prostate cancer who are candidates for radical prostatectomy.

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

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

From cannabis initiation to daily use: educational inequalities in consumption behaviours over three generations in France

AIMS

The diffusion of cannabis initiation has been accompanied by a reversal in the educational gradient: contrary to older generations, the less educated in recent generations are more likely to initiate than the more educated. We tested whether the educational gradient for the transition from initiation to daily use evolved in the same way.

DESIGN/SETTING

A French telephone random survey conducted in 2010 (21 818 respondents aged 15-64 years), asking interviewees about their ages at initiation to daily use, if any.

PARTICIPANTS

A total of 6824 cannabis initiators aged 18-64 years at data collection. Three birth cohort groups (generations) were compared: 1946-60 (n = 767), 1961-75 (n = 2632) and 1976-92 (n = 3425) with, respectively, 47, 42 and 45% of women.

MEASURES

Risks of transition to daily use from ages 11-34 were compared through time-discrete logistic regressions and educational gradients were quantified through a relative index of inequality (RII). Control variables include age and time-varying variables (ages at tobacco daily use, at first drunkenness and at first other use of an illicit drug in a list of 13 products).

FINDINGS

Twenty-four per cent of the initiators reported daily use before age 35, the proportions tripling from the oldest to the youngest generation (from 11.7 to 38.6% in men, from 7.7 to 22.2% in women). Whatever the generation, the less educated initiators more often shifted to daily use than the most educated: from the oldest to the youngest generation, RII = 2.13, 95% confidence interval (CI) = [0.65, 7.02]; 2.19 95% CI = [1.33, 3.63]; and 2.24, 95% CI = [1.60, 3.15] in men; RII = 3.31, 95% CI = [0.75, 14.68]; 3.17, 95% CI = [1.49, 6.76]; and 3.56, 95% CI = [2.07, 6.14] in women, respectively.

CONCLUSION

In France, the risk of transition from cannabis initiation to daily use has remained consistently higher among less educated cannabis initiators over three generations (1946-60, 1961-75, 1976-92), in contrast to what is observed for initiation.

Racial and Gender Disparities in Incidence of Lung and Bronchus Cancer in the United States: A Longitudinal Analysis

Background

Certain population groups in the United States carry a disproportionate burden of cancer. This work models and analyzes the dynamics of lung and bronchus cancer age-adjusted incidence rates by race (White and Black), gender (male and female), and prevalence of daily smoking in 38 U.S. states, the District of Columbia, and across eight U.S. geographic regions from 1999 to 2012.

Methods

Data, obtained from the U.S. Cancer Statistics Section of the Centers for Disease Control and Prevention, reflect approximately 77% of the U.S. population and constitute a representative sample for making inferences about incidence rates in lung and bronchus cancer (henceforth lung cancer). A longitudinal linear mixed-effects model was used to study lung cancer incidence rates and to estimate incidence rate as a function of time, race, gender, and prevalence of daily smoking.

Results

Between 1999 and 2012, age-adjusted incidence rates in lung cancer have decreased in all states and regions. However, racial and gender disparities remain. Whites continue to have lower age-adjusted incidence rates for this cancer than Blacks in all states and in five of the eight U.S. geographic regions. Disparities in incidence rates between Black and White men are significantly larger than those between Black and White women, with Black men having the highest incidence rate of all subgroups. Assuming that lung cancer incidence rates remain within reasonable range, the model predicts that the gender gap in the incidence rate for Whites would disappear by mid-2018, and for Blacks by 2026. However, the racial gap in lung cancer incidence rates among Black and White males will remain. Among all geographic regions, the Mid-South has the highest overall lung cancer incidence rate and the highest incidence rate for Whites, while the Midwest has the highest incidence rate for Blacks. Between 1999 and 2012, there was a downward trend in the prevalence of daily smokers in both genders. However, males have significantly higher rates of cigarette smoking than females at all time points. The highest and lowest prevalence of daily smoking are found in the Mid-South and New England, respectively. There was a significant correlation between lung cancer incidence rates and smoking prevalence in all geographic regions, indicating a strong influence of cigarette smoking on regional lung cancer incidence rates.

Conclusion

Although age-adjusted incidence rates in lung cancer have decreased throughout the U.S., racial and gender disparities remain. This longitudinal model can help health professionals and policy makers make predictions of age-adjusted incidence rates for lung cancer in the U.S. in the next five to ten years.

Gender, education and Russia's tobacco epidemic: A life-course approach

While a number of studies, based on cross-sectional data for Russia, have documented strong increases in female smoking during the past two decades, the analysis of longer-term trends in smoking prevalence is hampered by the lack of representative data for the Soviet era. In this paper we create life-course smoking histories based on retrospective data from the Russia Longitudinal Monitoring Survey of HSE (RLMS-HSE) and the Global Adult Tobacco Survey (GATS) which allow us to examine the dynamics of smoking patterns over the past 7 decades. We find that smoking rates differ most strongly by gender within all cohorts, but that this differential has decreased over time, driven by increases in female smoking and more recently by decreases in smoking among men. For both genders we observe that the education gradient has become steeper over time, with smoking rates having increased at a higher rate among those with the lowest educational attainment. These findings suggest that the development of smoking in Russia mirrors that described in the model of the tobacco epidemic and observed in Western high-income countries.

Social disparities in parental smoking and young children's exposure to secondhand smoke at home: a time-trend analysis of repeated cross-sectional data from the German KiGGS study between 2003-2006 and 2009-2012

Background

Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour.

Methods

The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income.

Results

The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households.

Conclusions

The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.

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

Objectives

Smoking contributes to socio-economic health inequalities; but it is unclear how smoking inequalities emerge at a young age. So far, little attention has been paid to the role of friendship ties. We hypothesised that the combination of peer exposure and friendship social homophily may contribute to socio-economic inequalities in smoking at school.

Methods

In 2013, a social network survey was carried out in 50 schools in six medium-size European cities (Namur, Tampere, Hanover, Latina, Amersfoort, and Coimbra). Adolescents in grades corresponding to the 14-to-16 age group were recruited (n = 11.015, participation rate = 79.4 %). We modelled adolescents’ smoking behaviour as a function of socio-economic background, and analysed the mediating role of social homophily and peer exposure.

Results

Lower socio-economic groups were more likely to smoke and were more frequently exposed to smoking by their close and distant friends, compared with adolescents of higher SES. The smoking risk of the lowest socio-economic group decreased after controlling for friends smoking and social homophily.

Conclusions

Smoking socio-economic inequalities amongst adolescents are driven by friendship networks.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-016-0830-z) contains supplementary material, which is available to authorized users.

Prevalence and Associated Factors of Passive Smoking among Women in Jilin Province, China: A Cross-Sectional Study

Background: The present study aimed to investigate the prevalence and associated socio-demographic factors of passive smoking among women in Jilin Province, China. Methods: A cross-sectional study was conducted in 2012, using a self-reported questionnaire interview. A representative sample of 9788 non-smoking women aged 18–79 years was collected in Jilin Province of China by a multistage stratified random cluster sampling design. Descriptive data analysis and 95% confidence intervals (CI) of prevalence/frequency were conducted. Multivariable logistic regressions were used to examine the associated socio-demographic factors of passive smoking. Results: The overall prevalence of passive smoking among non-smoking women in Jilin Province was 60.6% (95% CI: 59.3–61.8), 58.3% (95% CI: 56.7–59.9) from urban areas, and 63.4% (95% CI: 61.6–65.3) from rural areas. Twenty-six percent (95% CI: 24.9–27.1) of the non-smoking women reported daily passive smoking, of which 42.9% (95% CI: 41.6–44.1) reported passive smoking at home, and 5.1% (95% CI: 4.5–5.7) reported passive smoking in restaurants. Women in urban areas were less likely to be passive smokers than those in rural ones (OR-Odds Ratio: 0.825, 95% CI: 0.729–0.935), elderly women were less likely to be passive smokers than younger women (55–64 years OR: 0.481, 95% CI: 0.342–0.674; 65–79 years OR: 0.351, 95% CI: 0.241–0.511). Seperated/divorced women were less likely to be passive smokers (OR: 0.701, 95% CI: 0.500–0.982), and widowed women (OR: 0.564, 95%CI: 0.440–0.722), as the married were the reference group. Retired women second-hand smoked due to environmental causes significantly less than manual workers (OR: 0.810, 95% CI: 0.708–0.928). Women with a monthly family income of more than 5000 RMB were less likely to be passive smokers than those with an income less than 500 RMB (OR: 0.615, 95% CI: 0.432–0.876). Conclusions: The prevalence of passive smoking is lower than that reported in 2010 Global Adult Tobacco Survey (GATS) China, but passive smoking is still prevalent and has been an acute public health problem among non-smoking women in Jilin Province, China. Our findings suggest an urgent need for tobacco control and the efforts of public health should be both comprehensive and focus on high-risk populations in Jilin Province, China.

Does a Change Over All Equal a Change in All? Testing for Polarized Alcohol Use Within and Across Socio-Economic Groups in Germany

AIMS

This study aimed at testing whether drinking volume and episodic heavy drinking (EHD) frequency in Germany are polarizing between consumption levels over time. Polarization is defined as a reduction in alcohol use among the majority of the population, while a subpopulation with a high intake level maintains or increases its drinking or its EHD frequency. The polarization hypothesis was tested across and within socio-economic subgroups.

METHOD

Analyses were based on seven cross-sectional waves of the Epidemiological Survey of Substance Abuse (ESA) conducted between 1995 and 2012 (n = 7833-9084). Overall polarization was estimated based on regression models with time by consumption level interactions; the three-way interaction with socio-economic status (SES) was consecutively introduced to test the stability of effects over socio-economic strata. Interactions were interpreted by graphical inspection.

RESULTS

For both alcohol use indicators, declines over time were largest in the highest consumption level. This was found within all SES groups, but was most pronounced at low and least pronounced at medium SES.

CONCLUSION

The results indicate no polarization but convergence between consumption levels. Socio-economic status groups differ in the magnitude of convergence which was lowest in medium SES. The overall decline was strongest for the highest consumption level of low SES.

Women and smoking—prices and health warning messages: evidence from Spain

OBJECTIVE

In Spain, fewer men are smoking every year yet the number of women smokers remains relatively high. This paper examines the impact of two anti-smoking policies (increased prices and obligatory pictorial health warning labels) on womens smoking decisions; generation cohorts are used to elucidate the determinants of those decisions.

DATA SOURCE

We have drawn 48,755 observations of women living in Spain from the Spanish National Health Surveys of 2001, 2003, 2006 and 2011.

DATA SYNTHESIS

Among the main results, we highlight that belonging to a particular generation modulates the manner in which individual characteristics and tobacco policies determine smoking decisions. For example, women's smoking was not considered as socially acceptable until the 1960s and therefore older women have lower smoking rates. However, for the younger female cohorts (generations X and Y) smoking was seen as an act of rebellion and modernity, so women belonging to these groups, irrespective of educational level, are more likely to smoke.

CONCLUSIONS

The price of cigarettes and pictorial health warning labels on cigarette packets also influence the smoking behaviour of Spanish women.