Impact of the 1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by socioeconomic status

Thirty-eight-year trends of educational differences in smoking in Finland

Objectives

Smoking is declining, but it is unevenly distributed among population groups. Our aim was to examine the socio-economic differences in smoking during 1978–2016 in Finland, a country with a history of strict tobacco control policy.

Methods

Annual population-based random sample data of 25–64-year-olds from 1978 to 2016 (N = 104,315) were used. Response rate varied between 84 and 40%. In addition to logistic regression analysis, absolute and relative educational differences in smoking were examined.

Results

Smoking was more prevalent among the less educated but declined in all educational groups during the study period. Both absolute and relative differences in smoking between the less and highly educated were larger at the end of the study period than at the beginning. Cigarette price seemed to have a larger effect on the smoking among the less educated.

Conclusions

Socio-economic differences in smoking among the Finnish adult population have increased since the 1970s until 2016. Further actions are needed, especially focusing on lower socio-economic positions, to tackle inequalities in health. They should include support for smoking cessation and larger cigarette tax increases.

Electronic supplementary material

The online version of this article (10.1007/s00038-019-01228-x) contains supplementary material, which is available to authorized users.

Individual and contextual determinants of perceived peer smoking prevalence among adolescents in six European cities

BACKGROUND

Young people perceiving a high peer smoking prevalence are more likely to initiate smoking. It is unclear which factors contribute to perceived peer smoking prevalence and if these factors vary according to education. This study aimed to assess the determinants of perceived smoking prevalence and assessed its variation at school and country-level.

METHODS

Data of 10,283 14-17-year-old students in 50 secondary schools in six European cities were derived from the 2013 SILNE survey. The outcome was the perceived smoking prevalence score among peers at school (0-10 scale, 10 represented 100% smoking prevalence). Multilevel linear regression models estimated the associations of factors with perceived prevalence score and variance at school and country-levels. Analyses were also stratified by academic achievement of the adolescent and parental education.

RESULTS

Determinants of a higher perceived prevalence score were female sex, ever smoking, having friends who smoke, low academic achievement, low parental educational level, and higher actual prevalence of smoking in the school. The perceived prevalence score was not associated with school policies or with the availability of cigarettes near the school. Determinants were very similar across levels of academic achievement and parental education. Perceived prevalence scores substantially varied between schools and countries: 10% and 11% of total variance was related to schools and countries respectively.

CONCLUSION

Across educational levels, perceptions of peer smoking are strongly determined by both individual characteristics and school and national contexts. Future studies should assess why perceived smoking prevalence varies between schools and countries and identify modifiable factors.

Tobacco Control and Socioeconomic Inequalities in Adolescent Smoking in Europe

INTRODUCTION

The strength of national tobacco control varies by country, but it is unclear how this relates to smoking in adolescents of high and low SES. This study examined the association between tobacco control policies and adolescent smoking and investigated the differences in this association between adolescents of high and low SES.

METHODS

Data of 90,351 adolescents aged 15-16 years from 13 European countries were obtained from the 2003, 2007, and 2011 European Survey Project on Alcohol and other Drugs databases. Logistic regression analyses were performed in 2014 with a random intercept at the country level and with daily smoking as the outcome. The Tobacco Control Scale was the score for national tobacco control policy. SES was based on parental education.

RESULTS

In all studied countries, except Portugal, adolescent smoking prevalence rates were highest among low-SES respondents. Stronger tobacco control policies were associated with lower smoking rates in all three survey waves (2003, OR=0.75, 95% CI=0.55, 1.01; 2007, OR=0.84, 95% CI=0.73, 0.98; 2011, OR=0.85, 95% CI=0.74, 0.98). The association was consistently stronger in high-SES than in low-SES individuals, but the difference was not statistically significant.

CONCLUSIONS

Countries with stronger tobacco control policies tend to have lower smoking rates. We are unable to demonstrate significant socioeconomic inequalities in the effect of tobacco control policies on adolescent smoking.

Widening educational inequalities in adolescent smoking following national tobacco control policies in the Netherlands in 2003: a time-series analysis

BACKGROUND AND AIMS

In 2003, the Netherlands introduced tobacco control policies, including bans on tobacco sales to minors, advertising and sponsoring and tobacco sales in government institutions. We examined the extent to which these policies were associated with a change in educational inequalities in adolescent smoking.

DESIGN

Repeated cross-sectional survey.

SETTING

The Netherlands, 1992-2011.

PARTICIPANTS

A total of 43 527 14-19-year-old adolescents.

MEASUREMENTS

Data were obtained from the national Youth Smoking Monitor. We used logistic regression analyses to model the immediate change in daily smoking prevalence in 2003, the trends and the changes in trends. Models included interactions between educational level (high versus low, based on the educational track of the respondent) and, respectively, period (after versus before 2003), time and time × period.

FINDINGS

Before 2003 the smoking trend declined slightly, and the decline was comparable for students of both high and low educational levels. Immediately after tobacco policies were introduced, daily smoking prevalence dropped for the total population [regression coefficient (β) = -0.340, 95% confidence interval (CI) = -0.445; -0.236]. This drop was larger for high educational level compared to low educational level (β interaction = -0.400, 95% CI = -0.623; -0.176). After 2003, trends in educational inequalities in smoking stabilized.

CONCLUSIONS

Following the introduction of new tobacco control policies in the Netherlands in 2003, smoking prevalence rates decreased among adolescents of both higher and lower educational levels. However, socio-economic inequalities in adolescent smoking increased.

Drinking, smoking, and educational achievement: cross-lagged associations from adolescence to adulthood

BACKGROUND

Adolescent substance use is associated with lower educational achievement but the directionality of the association remains uncertain. We analyzed data on drinking, smoking and educational achievement to study the associations between substance use and education from early adolescence to young adulthood.

METHODS

Longitudinal data from four time points (ages 12, 14, 17, and 19-27 years) from a population-based cohort study of Finnish twin individuals were used to estimate bivariate cross-lagged path models for substance use and educational achievement, adjusting for sex, parental covariates, and adolescent externalizing behavior. A total of 4761 individuals (49.4% females) were included in the analyses. Educational achievement was assessed with teacher-reported grade point average at ages 12 and 14, and with self-reported student status and completed education at age 17 and in young adulthood. From self-reported questionnaire items, frequency of any drinking, frequency of drinking to intoxication, any smoking and daily smoking were analyzed.

RESULTS

Alcohol use and smoking behaviors at ages 12 and 14 predicted lower educational achievement at later time points even after previous achievement and confounding factors were taken into account. Lower school achievement in adolescence predicted a higher likelihood of engaging in smoking behaviors but did not predict later alcohol use. Higher educational attainment at age 17 predicted more frequent drinking in young adulthood.

CONCLUSIONS

Adolescent drinking behaviors are associated with lower future educational achievement independently of prior achievement, whereas smoking both predicts and is predicted by lower achievement. Early substance use indexes elevated risk for poor educational outcomes.

Socioeconomic status across the life course and all-cause and cause-specific mortality in Finland

We used high quality register based data to study the relationship between childhood and adult socio-demographic characteristics and all-cause and cause-specific mortality at ages 35-72 in Finland among cohorts born in 1936-1950. The analyses were based on a 10% sample of households drawn from the 1950 Finnish Census of Population with the follow-up of household members in subsequent censuses and death records beginning from the end of 1970 through the end of 2007. The strengths of these data come from the fact that neither childhood nor adult characteristics are self reported and thus are not subject to recall bias, misreporting and no loss to follow-up after age 35. In addition, the study population includes several families with at least two children enabling us to control for unobserved family characteristics. We documented significant associations between early life social and family conditions on all-cause mortality and cause-specific mortality, with protective effects of higher childhood socio-demographic characteristics varying between 10% and 30%. These associations were mostly mediated through adult educational attainment and occupation, suggesting that the indirect effects of childhood conditions were more important than their direct effects. We further found that adult socioeconomic status was a significant predictor of mortality. The associations between adult characteristics and mortality were robust to controls for observed and unobserved childhood characteristics. The results imply that long-term adverse health consequences of disadvantaged early life social circumstances may be mitigated by investments in educational and employment opportunities in early adulthood.

The changing contribution of smoking to educational differences in life expectancy: indirect estimates for Finnish men and women from 1971 to 2010

BACKGROUND

We estimated the contribution of smoking to educational differences in mortality and life expectancy between 1971 and 2010 in Finland.

METHODS

Eight prospective datasets with baseline in 1970, 1975, 1980, 1985, 1990, 1995, 2000 and 2005 and each linked to a 5-year mortality follow-up were used. We calculated life expectancy at age 50 years with and without smoking-attributable mortality by education and gender. Estimates of smoking-attributable mortality were based on an indirect method that used lung cancer mortality as a proxy for the impact of smoking on mortality from all other causes.

RESULTS

Smoking-attributable deaths constituted about 27% of all male deaths above age 50 years in the early 1970s and 17% in the period 2006-2010; these figures were 1% and 4% among women, respectively. The life expectancy differential between men with basic versus high education increased from 3.4 to 4.7 years between 1971-1975 and 2006-2010. In the absence of smoking, these differences would have been 1.5 and 3.4 years, 1.9 years (55%) and 1.3 years (29%) less than those observed. Among women, educational differentials in life expectancy between the most and least educated increased from 2.5 to 3.0 years. This widening was nearly entirely accounted for by the increasing impact of smoking. Among women the contribution of smoking to educational differences had increased from being negligible in 1971-1975 to 16% in 2006-2010.

CONCLUSIONS

Among men, the increase in educational differences in mortality in the past decades was driven by factors other than smoking. However, smoking continues to have a major influence on educational differences in mortality among men and its contribution is increasing among women.

Evening types are more often current smokers and nicotine-dependent-a study of Finnish adult twins

AIMS

To examine the association between diurnal type and smoking status and nicotine dependence (ND).

DESIGN

A cohort study using random-effects model regressions for repeated longitudinal panel data was used to analyse smoking status by diurnal type. Regression analyses examined the association between diurnal type and ND.

PARTICIPANTS

A total of 23, 289 same-sex adult twin individuals from Finnish Twin Cohort. Nicotine dependence was studied in a subsample of 676 twin individuals.

MEASUREMENTS

Subjects were classified by self-report into four categories: morning type, somewhat morning type, somewhat evening type, evening type (in 1981). Smoking status was defined as current and ever smoking (in 1975, 1981 and 1990). ND was measured by DSM-IV and Fagerström Test for Nicotine Dependence (FTND) (during 2001-05). Findings  Evening types of both genders were much more likely to be current (OR = 2.91, 95% CI 2.50, 3.38) and life-time smokers (OR = 2.67, 95% CI 2.96, 4.07) compared to morning types. Evening types were less likely to stop smoking. The risk of nicotine dependence assessed by DSM-IV criteria was higher among evening types (OR = 2.78, 95% CI 1.64, 4.72). Evening types scored 0.59 (95% CI 0.01, 1.17) points higher than morning types on the FTND. Adjustment for potential confounders did not change these associations.

CONCLUSIONS

Being an evening type is associated independently with a higher risk of being a current smoker, being more highly dependent upon cigarettes and a lower likelihood of stopping smoking. Understanding the cause of these associations could elucidate the causes of tobacco addiction.

Attitudes to new smoking restrictions and second-hand smoke among young Finnish males

Aims: Relatively little is known about the attitudes of young people to restrictions on smoking in public places and to environmental second-hand smoke in housing estates. The objective was to explore the attitudes of young male adults after the new smoke-free legislation was implemented in Finland. Methods: A survey of 1167 Finnish male military conscripts was performed. The main outcome variables were their attitudes to the new restrictions on smoking in public places and concerns about second-hand smoke in the home originating from their neighbours. Results: Almost half of the youths (43.5%) reported that they supported the more restrictive smoking regulations, with 44.8% having a neutral view. Only 16.0% of the respondents were irritated about the second-hand smoke entering to their house from outside and 48.6% were not concerned about smoking in their neighbourhood. A total of 555 (47.6%) conscripts were current smokers. Current smokers were more often totally opposed to the legislation and had less negative views about the exposure to second-hand smoke than non-smokers. Strong nicotine dependence increased the feelings of anxiety and stigmatisation when the new restrictions were introduced. Conclusions: Finnish young men do accept new smoking restrictions. However, smoking with high nicotine dependence was surprisingly common among these young men and the negative attitude to the legislation can be traced to this group of smokers. The repulsion felt towards second-hand smoke by non-smokers represents an opportunity for public health initiatives to guarantee a smoke-free environment in public and private places.

Marital status, educational level and household income explain part of the excess mortality of survey non-respondents

Survey respondents and non-respondents differ in their demographic and socio-economic position. Many of the health behaviours are also known to be associated with socio-economic differences. We aimed to investigate how much of the excess mortality of survey non-respondents can be explained by the socio-economic differences between respondents and non-respondents. Questionnaire-based adult health behaviour surveys have been conducted in Finland annually since 1978. Data from the 1978 to 2002 surveys, including non-respondents, were linked with mortality data from the Finnish National Cause of Death statistics and with demographic and socio-economic register data (marital status, education and household income) obtained from Statistics Finland. The mortality follow-up lasted until 2006, in which period there were 12,762 deaths (7,994 in men and 4,768 in women) during the follow-up. Total and cause-specific mortality were higher among non-respondents in both men and women. Adjusting results for marital status, educational level and average household income decreased the excess total and cause-specific mortality of non-respondents in both men and women. Of the total excess mortality of non-respondents, 41% in men and 20% in women can be accounted for demographic and socio-economic factors. A part of the excess mortality among non-respondents can be accounted for their demographic and socio-economic characteristics. Based on these results we can assume that non-respondents tend to have more severe health problems, acute illnesses and unhealthy behaviours, such as smoking and excess alcohol use. These can be reasons for persons not taking part in population surveys.