Educational inequalities in initiation, cessation, and prevalence of smoking among 3 Italian birth cohorts

Cancers attributable to tobacco smoking in Italy in 2020

BACKGROUND

Tobacco smoking is still frequent in Italy and a major cause of cancer globally. We estimated the burden of smoking-related cancer in Italy.

METHODS

To calculate the population attributable fraction (PAF), we adopted a counterfactual scenario for which all individuals never smoked. The PAF of current and former smoking and second-hand smoke (SHS) was estimated for cancers associated with these habits according to the International Agency for Research on Cancer. Relative risk estimates and prevalence of exposure were derived from large-scale studies and national surveys, respectively. A 20-year latency period between exposure and cancer was considered. Cancer incidence data for 2020 and mortality data for 2017 were obtained from the Italian Association of Cancer Registries.

RESULTS

Tobacco smoking caused, in men and women respectively, 90.0 % and 58.3 % of lung; 67.8 % and 53.5 % of pharyngeal; 47.0 % and 32.2 % of bladder; 45.9 % and 31.7 % of oral; 36.6 % and 23.6 % of esophageal; 23.0 % and 14.0 % of pancreatic cancer and lower percentages of cancers at other sites. Tobacco smoking accounted for 23.9 % and 7.7 % of new cancer cases in 2020, and 32.1 % and 11.3 % of cancer deaths in 2017 in men and women, respectively, corresponding to 17.3 % of cases and 24.5 % of cancer deaths overall. The PAF of lung cancer due to SHS in never smoking women married with smokers was 13.0 %.

CONCLUSIONS

Tobacco smoking is a primary cause of cancer in Italy in both sexes. Tobacco control policies are warranted.

[Public mental health from an international perspective: from "shifting the curve" to inclusion of vulnerable populations]

In recent years, efforts in the field of public mental health have increased that seek to promote mental health and mental health literacy at population level and yield advances in the prevention, treatment and care of mental health conditions. This paper provides an overview of contemporary conceptualisations of indicators and determinants of public mental health as well as population-based intervention strategies from an international perspective. Current conceptual and methodological challenges of so-called high-risk, whole-population and vulnerable population strategies are critically discussed. Future efforts in research, policy and practice need to address fundamental causes of social and health inequalities, drawing on all societal fields, to contribute to improving population mental health.

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.

Total and Free Sugar Levels and Main Types of Sugars Used in 18,784 Local and Imported Pre-Packaged Foods and Beverages Sold in Hong Kong

There is limited information regarding the free sugar content of pre-packaged foods in Hong Kong. This study aims to assess the free sugar content and identify the most frequently used free sugar ingredients (FSI) in pre-packaged foods in Hong Kong. Data from 18,784 products from the 2019 FoodSwitch Hong Kong database were used in this analysis. Ingredient lists were screened to identify FSI. Total sugar content was derived from nutrition labels on packaging. Free sugar content was estimated based on adaptation of a previously established systematic methodology. Descriptive statistics of the total sugar and free sugar content, as well as the mean ± SD contribution of free sugar to total sugar of the audited products were calculated, stratified by food groups. Almost two-thirds (64.5%) of the pre-packaged foods contained at least one FSI. 'Sugar (sucrose)' was the most popular FSI that was found in more than half (54.7%) of the products. 'Fruit and vegetable juices' (median 10.0; IQR 8.3-11.5 g/100 mL) were found to have a higher median free sugar content than 'Soft drinks' (8.0; 6.0-10.6 g/100 mL). Mean ± SD contribution of free sugar to the total sugar content was 65.8 ± 43.4%, with 8 out of 14 food groups having >70% total sugar as free sugar. To conclude, free sugar, especially sucrose, was extensively used in a wide variety of pre-packaged products sold in Hong Kong. Further studies are needed to assess the population intake of free sugar in Hong Kong to inform public health policy on free sugar reduction.

Trends in socioeconomic inequality of periodontal health status among Dutch adults: a repeated cross-sectional analysis over two decades

Background

Studies exclusively focusing on trends in socioeconomic inequality of oral health status in industrialized countries are relatively sparse. This study aimed to assess possible differences in oral hygiene and periodontal status among people of different socioeconomic status (SES) in the Netherlands over two decades.

Methods

A repeated cross-sectional analysis of 3083 participants aged 25–54 years was conducted on the Dutch National Oral Health Surveys of 1995, 2002, 2007, and 2013. Plaque-free was defined according to the Simplified Oral Hygiene Index (OHI-S = 0). Periodontal status was classified in two different ways, either periodontal health/disease (probing pocket depth index [PDI] = 0/ ≥ 1) or with/without deep pockets (PDI = 2). We used the regression-based absolute and relative effect index to measure the absolute and relative socioeconomic inequalities. Multivariable logistic regressions were used to explore temporal trends in oral hygiene and periodontal status by low- and high-SES groups.

Results

Age-standardized percentages of individuals with plaque-free increased in the whole population from 1995 to 2013 (12.7% [95% CI 10.5–14.9] to 28.1% [24.8–31.5]). Plaque-free showed significant socioeconomic differences in absolute and relative inequalities in 2007 and 2013. Between 1995 and 2013, age-standardized percentage of periodontal health increased (from 51.4% [48.1–54.7] to 60.6% [57.0–64.1]). The significant absolute inequalities for periodontal health were seen in 2002 and 2013. The relative scale presented a similar pattern. Regarding deep pockets, there was little difference in the age-standardized overall prevalence in 1995 versus 2013 (from 6.5% [4.9–8.2] to 5.4% [3.7–7.0]). The significant absolute and relative inequalities in deep pockets prevalence were found in 1995. Yet, all interaction terms between survey year and SES did not reach significance (plaque-free: P = .198; periodontal health: P = .490; deep pockets: P = .678).

Conclusions

Socioeconomic inequalities in oral hygiene and periodontal status were present in the Netherlands in the last two decades.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis

Purpose

To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries.

Methods

Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality.

Results

In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women.

Conclusions

Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00247-2.

The association between gender roles and smoking initiation among women and adolescent girls

Smoking cigarettes is a leading global cause of preventable death and disease. Men historically smoke more than women, but the prevalence of smoking among women in low and middle-income countries is increasing at an alarming rate. Understanding the factors that influence smoking initiation among women and girls is needed to address the growing epidemic of women smokers and the looming impact on women's health worldwide. We assume that smoking initiation is embedded in socio-culturally influenced gendered context and use a social cognitive model with a gendered lens as a framework for organizing and synthesizing the research. Guided by this framework, we identified gaps in the literature and make recommendations for future research in this review paper. The results suggest that psychological and environmental determinants are rooted in fluctuating cultural influences and values, but few research studies provide a gendered analysis or systematically examine these factors in the context of gender and culture. Sex/gender is a significant construct through which women and girls experience the psychological, environmental, and other influences on smoking initiation. Much more research is needed to understand the psychological and environmental influences as well as the intersection of gender roles and other social categories on female smoking initiation.

Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review

One explanation for the increasing smoking-related health inequalities is the limited access of lower socioeconomic status (SES) smokers to smoking cessation support. In order to understand this limited access - and to eventually improve accessibility - we provide a structured overview of the barriers that lower SES smokers face in the successive phases of access to cessation support. Our literature review included 43 papers on barriers of access to cessation support for lower SES smokers, published before June 2016. We used the access to health care framework to categorize the extracted barriers into (a) either the abilities of smokers or dimensions of cessation support and (b) one of the successive phases of access to support. We found that lower SES smokers encounter many barriers. They are present in all phases of access to cessation support, and different barriers may be important in each of these phases. We also found that each phase transition is hampered by barriers related to both the abilities of smokers and the dimensions of cessation support, and that these barriers tend to interact, both with each other and with the disadvantaged living conditions of lower SES smokers. In conclusion, reducing smoking-related health inequalities by improving lower SES smokers' access to smoking cessation support requires a comprehensive approach. Our structured overview of barriers may serve as a starting point for tailoring such an approach to the multitude of barriers that prevent lower SES smokers from accessing cessation support, while simultaneously taking into account their disadvantaged living conditions.

Paradoxical Impact of a Patient-Handling Intervention on Injury Rate Disparity Among Hospital Workers

OBJECTIVES

To test whether a comprehensive safe patient-handling intervention, which successfully reduced overall injury rates among hospital workers in a prior study, was differentially effective for higher-wage workers (nurses) versus low-wage workers (patient care associates [PCAs]).

METHODS

Data were from a cohort of nurses and PCAs at 2 large hospitals in Boston, Massachusetts. One hospital received the intervention in 2013; the other did not. Using longitudinal survey data from 2012 and 2014 plus longitudinal administrative injury and payroll data, we tested for socioeconomic differences in changes in self-reported safe patient-handling practices, and for socioeconomic differences in changes in injury rates using administrative data.

RESULTS

After the intervention, improvements in self-reported patient-handling practices were equivalent for PCAs and for nurses. However, in administrative data, lifting and exertion injuries decreased among nurses (rate ratio [RR] = 0.64; 95% confidence interval [CI] = 0.41, 1.00) but not PCAs (RR = 1.10; 95% CI = 0.74,1.63; P for occupation × intervention interaction = 0.02).

CONCLUSIONS

Although the population-level injury rate decreased after the intervention, most improvements were among higher-wage workers, widening the socioeconomic gap in injury and exemplifying the inequality paradox. Results have implications for public health intervention development, implementation, and analysis.

Income as a moderator of psychological stress and nicotine dependence among adult smokers

BACKGROUND

Perceived stress and psychological distress are associated with more cigarette craving and withdrawal, higher nicotine dependence, and less success during quit attempts. Low income smokers have disproportionately higher rates of smoking and may be particularly vulnerable to the effects of stress on smoking dependence. The aim of the current study was to assess if lower income smokers have a stronger association between stress and nicotine dependence than higher income smokers.

METHODS

Data were obtained from the Pennsylvania Adult Smoking Study, which included 351 daily smokers. Subjects completed PhenX Toolkit and other self-report measures of socioeconomic factors, the 10-item Perceived Stress Scale, Kessler Psychological Distress Scale (K6), Fagerstrom Test for Nicotine Dependence (FTND), and the Hooked on Nicotine Checklist (HONC). Moderation analyses using linear regression examined income-related differences in the association between stress and nicotine dependence.

RESULTS

Income groups were categorized by an annual household income of $50,000 based on visual-inspection of scatter plots of income by nicotine dependence. Compared to higher income smokers, lower income smokers had significantly higher mean levels of nicotine dependence on the FTND [3.74 vs. 4.79, p < 0.001], perceived stress [15.63 vs. 17.95, p = 0.004], and psychological distress [5.30 vs. 6.86, p = 0.001], respectively. There were interaction effects, such that lower income smokers had a strong, positive associations between FTND and perceived stress (B = -0.11, CI = -0.17 to -0.04, p = 0.002) and psychological distress (B = -0.13, CI = -0.25 to -0.02, p = 0.022) whereas no association was found in higher income smokers. No significant moderation effects were found for the HONC or when income groups were categorized by U.S. federal poverty level.

CONCLUSIONS

The results highlight that the relationship between increasing stress and FTND was found in lower but not higher income groups. Future research should examine socioeconomic, environmental and psychosocial factors that may facilitate increased smoking during stress-induced craving.

Emerging Trends in Clinical Research: With Implications for Population Health and Health Policy

Policy Points: Significant advances in clinical medicine that have broader societal relevance may be less accessible to population health researchers and policymakers because of increased specialization within fields. We describe important recent clinical advances and discuss their broader societal impact. These advances include more expansive strategies for disease prevention, the rise of precision medicine, applications of human microbiome research, and new and highly successful treatments for hepatitis C infection. These recent developments in clinical research raise important issues surrounding health care costs and equitable resource allocation that necessitate an ongoing dialogue among the fields of clinical medicine, population health, and health policy.

CONTEXT

Developments in clinical medicine have important implications for population health, and there is a need for interdisciplinary engagement among clinical medicine, the social sciences, and public health research. The aim of this article is to help bridge the divide between these fields by exploring major recent advances in clinical medicine that have important implications for population health.

METHODS

We reviewed the most cited articles published from 2010 to 2015 in 5 high-impact clinical journals and selected 5 randomized controlled trials and 2 related clinical practice guidelines that are broadly relevant to population health and policy.

FINDINGS

We discuss the following themes: (1) expanding indications for drug therapy and the inherent medicalization of the population as highlighted by studies and clinical guidelines supporting lower blood pressure targets or widespread statin use; (2) the tension in nutritional research between quantifying the impact of isolated nutrients and studying specific foods and dietary patterns, for example, the role of the Mediterranean diet in the primary prevention of cardiovascular disease; (3) the issue of high medication costs and the challenge of providing equitable access raised by the development of new and effective treatments for hepatitis C infection; (4) emerging clinical applications of research on the human microbiome as illustrated by fecal transplant to treat Clostridium difficile infections; and (5) the promise and limitations of precision medicine as demonstrated by the rise of novel targeted therapies in oncology.

CONCLUSIONS

These developments in clinical science hold promise for improving individual and population health and raise important questions about resource allocation, the role of prevention, and health disparities.

Does free or lower cost smoking cessation medication stimulate quitting? Findings from the International Tobacco Control (ITC) Netherlands and UK Surveys

OBJECTIVE

To investigate whether mentioning free or lower cost smoking cessation medication as a trigger for thinking about quitting is related to higher medication use, more quit attempts and quit success, and whether these associations are modified by education and income.

METHODS

Data were derived from the 2013 and 2014 surveys of the International Tobacco Control Netherlands (n=1164) and UK (n=768) cohort. Logistic regression analyses were used to assess associations between mentioning in 2013 that free/lower cost smoking cessation medication was a trigger for thinking about quitting smoking and the use of medication, quit attempts and smoking cessation in 2014.

RESULTS

37.0% of smokers in the UK and 24.9% of smokers in the Netherlands mentioned free/lower cost medication as a trigger for thinking about quitting. Smokers who mentioned this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR=4.19, p<0.001) and in the Netherlands (OR=2.14, p=0.033). The association between mentioning free/lower cost medication as a trigger for thinking about quitting and actual quit attempts was significant in the UK (OR=1.45, p=0.030), but not in the Netherlands (OR=1.10, p=0.587). There was no significant association with quit success. Associations did not differ across income and education groups.

CONCLUSION

Free/lower cost smoking cessation medication may increase the use of cessation medication and stimulate quit attempts among smokers with low, moderate and high education and income.

Tobacco use: prevalence, pattern, and predictors, among those aged 15-49 years in Nigeria, a secondary data analysis

INTRODUCTION

Tobacco use is a major global public health challenge. It is a risk factor for most leading causes of death, and its health impacts span from conception to adulthood. This study aims to analyse tobacco use data from the 2013 Nigerian Demographic and Health Survey (NDHS), assessing the prevalence, pattern, and socio-demographic correlates of tobacco use among Nigerians aged 15-49 years.

METHODS

A secondary data analysis involving 2013 NDHS was done. Data on 17 322 respondents were extracted from 36 800 participants. This number represents respondents with complete data on outcome variables of interest. Primary Sampling Unit defined on the basis of Enumeration Areas from the 2006 census was used. Head of selected household, all men and women aged 15-49 were studied. Data was collected using questionnaires. A chi-squared test and a binary logistic regression model were used in the analysis.

RESULTS

Generally, 6.6% of the respondents smoked cigarettes, 1.7% used snuff, 0.4% smoked pipe, and 0.2% chewed tobacco. Based on gender, 6.6% males and 6.3% females smoked cigarettes, 0.3% males and 0.4% females smoked cigarettes as well as used snuff. Predictors of cigarette use included being in age group 25-34 years (AOR 5.8; 95% CI 4.6-7.2), being ≥35 years (AOR 4.1; 95% CI 4.1-6.8), having attained primary education (AOR 1.4; 95% CI 1.2-1.8), living in north region (AOR 1.3; 95% CI 1.1-1.5), as well as being a Moslem (AOR 0.6; 95% CI 0.5-0.7).

CONCLUSIONS

A minor proportion of both genders uses tobacco with the commonest form being cigarettes. The commonest combination was cigarettes and snuff, even on stratification by gender. The identified predictors were age in categories, educational level and religion.

Australia's $40 per pack cigarette tax plans: the need to consider equity

In May 2016, the Australian Government announced that it would implement annual increases in tobacco excise of 12.5% up to and including 2020, raising the cost of a pack of cigarettes to $A40. This increase will lead to Australia having one of the highest prices of cigarettes in the world. Increasing the cost of tobacco is considered by public health experts to be one of the most effective strategies to reduce tobacco use, and is generally well supported by the public. However, tobacco tax increases differentially impact various subgroups of the population. Based on a review of existing literature, this paper examines some of the potential (unintended) consequences of the tax to individual and family income; illicit trade; social stigma and opportunities for lobbying by the tobacco industry. In light of these considerations, we offer strategies that might be used by policymakers to mitigate potential harms. While this paper focuses on the impacts primarily on populations in Australia, the consequences and strategies offered may be useful to other countries implementing tobacco excise increases.

Change in Neighborhood Disadvantage and Change in Smoking Behaviors in Adults: A Longitudinal, Within-individual Study

BACKGROUND

Evidence for an association between neighborhood disadvantage and smoking is mixed and mainly based on cross-sectional studies. To shed light on the causality of this association, we examined whether change in neighborhood socioeconomic disadvantage is associated with within-individual change in smoking behaviors.

METHODS

The study population comprised participants of the Finnish Public Sector study who reported a change in their smoking behavior between surveys in 2008/2009 and 2012/2013. We linked participants' residential addresses to a total population database on neighborhood disadvantage with 250 × 250-m resolution. The outcome variables were changes in smoking status (being a smoker vs. not) as well as the intensity (heavy/moderate vs. light smoker). We used longitudinal case-crossover design, a method that accounts for time-invariant confounders by design. We adjusted models for time-varying covariates.

RESULTS

Of the 3,443 participants, 1,714 quit, while 967 began to smoke between surveys. Smoking intensity increased among 398 and decreased among 364 participants. The level of neighborhood disadvantage changed for 1,078 participants because they moved residence. Increased disadvantage was associated with increased odds of being a smoker (odds ratio of taking up smoking 1.23 [95% confidence interval: 1.2, 1.5] per 1 SD increase in standardized national disadvantage score). Odds ratio for being a heavy/moderate (vs. light) smoker was 1.14 (95% confidence interval: 0.85, 1.52) when disadvantage increased by 1 SD.

CONCLUSIONS

These within-individual results link an increase in neighborhood socioeconomic disadvantage, due to move in residence, with subsequent smoking behaviors.

Factors across the life course predict women's change in smoking behaviour during pregnancy and in midlife: results from the National Child Development Study

BACKGROUND

Tobacco smoking before, during and after pregnancy remains one of the few preventable factors associated with poor health outcomes for mothers and their children. We investigate predictors across the life course for change in smoking behaviour during pregnancy and whether this change predicts smoking status in midlife.

METHODS

Data were from the National Child Development Study (1958 British birth cohort). We included female cohort members who reported a first pregnancy up to age 33 years. Among 1468 women who smoked before pregnancy, we examined predictors reported in childhood (age 11 years), adolescence (age 16 years) and early adulthood (age 23 years) of change in smoking behaviour from 12 months before to during pregnancy using log-binomial regression. The association between change in smoking behaviour during pregnancy and smoking status in midlife (age 55 years) was examined while adjusting for predictors across the life course.

RESULTS

Among prepregnancy smokers (39%), 26% reduced and 35% quit smoking during pregnancy. Parental smoking and lower social class during childhood, and early adulthood lower social class, depression, early smoking initiation, high smoking intensity, living with a smoker, no pregnancy planning and early motherhood were associated with lower probability of smoking reduction or cessation in pregnancy. Compared with women who smoked before and during pregnancy, women who reduced or quit were two times more likely to be non-smoker at age 55 years (95% CI 1.76 to 2.20).

CONCLUSIONS

Findings from this population-based birth cohort study lend support for smoking cessation strategies that target those at risk at various stages across the life course.

Comparison of Health and Risk Factors of Older, Working-age Australians, Italians and Italian-born Migrants to Australia, with Data from an Italian (PASSI), and an Australian (SAMSS) Risk Factor Surveillance System

Italian-born migrants (post-WWII) are the largest non-English-speaking background migrant group in South Australia. A cross-sectional, inter-country comparison using independent samples (40–69 years of age) from two (one in Australia, one in Italy) similar risk factor and chronic disease surveillance systems. None of the three groups (Italians, Australian-born and Italian-born Australians) had definitively worse health although the Italians had high rates for four of the seven risk factors reported (current high blood pressure, current high cholesterol, current smoking, eating less than five fruit and/or vegetables per day) than Australian-born and Italian-born Australians. Italian-born Australians had higher rates for insufficient physical activity, overweight/obese, poor self-reported health and diabetes. Australian respondents were more likely to report having two or more drinks of alcohol per day. Issues facing an ageing population require appropriate health care needs and an assessment of structural or cultural barriers to health services.

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.

Socioeconomic Inequalities in Smoking and Smoking Cessation Due to a Smoking Ban: General Population-Based Cross-Sectional Study in Luxembourg

This study aimed to measure changes in socioeconomic inequalities in smoking and smoking cessation due to the 2006 smoking ban in Luxembourg. Data were derived from the PSELL3/EU-SILC (Panel Socio-Economique Liewen Zu Letzebuerg/European Union--Statistic on Income and Living Conditions) survey, which was a representative survey of the general population aged ≥16 years conducted in Luxembourg in 2005, 2007, and 2008. Smoking prevalence and smoking cessation due to the 2006 smoking ban were used as the main smoking outcomes. Two inequality measures were calculated to assess the magnitude and temporal trends of socioeconomic inequalities in smoking: the prevalence ratio and the disparity index. Smoking cessation due to the smoking ban was considered as a positive outcome. Three multiple logistic regression models were used to assess social inequalities in smoking cessation due to the 2006 smoking ban. Education level, income, and employment status served as proxies for socioeconomic status. The prevalence of smoking decreased by 22.5% between 2005 and 2008 (from 23.1% in 2005 to 17.9% in 2008), but socioeconomic inequalities in smoking persisted. Smoking prevalence decreased by 24.2% and 20.2% in men and women, respectively; this difference was not statistically significant. Smoking cessation in daily smokers due to the 2006 smoking ban was associated with education level, employment status, and income, with higher percentages of quitters among those with a lower socioeconomic status. The decrease in smoking prevalence after the 2006 law was also associated with a reduction in socioeconomic inequalities, including differences in education level, income, and employment status. Although the smoking ban contributed to a reduction of such inequalities, they still persist, indicating the need for a more targeted approach of smoke-free policies directed toward lower socioeconomic groups.

Social Inequality in Cigarette Consumption, Cigarette Dependence, and Intention to Quit among Norwegian Smokers

BACKGROUND

The study aim was to examine the influence of education and income on multiple measures of risk of smoking continuation.

METHODS

Three logistic regression models were run on cigarette consumption, dependence, and intention to quit based on nationally representative samples (2007-2012) of approximately 1 200 current smokers aged 30-66 years in Norway.

RESULTS

The relative risk ratio for current versus never smokers was RRR 5.37, 95% CI [4.26-6.77] among individuals with low educational level versus high and RRR 1.53, 95% CI [1.14-2.06] in the low-income group versus high (adjusted model). Low educational level was associated with high cigarette consumption, high cigarette dependence, and no intention to quit. The difference in predicted probability for having high cigarette consumption, high cigarette dependence, and no intention to quit were in the range of 10-20 percentage points between smokers with low versus those with high educational level. A significant difference between low- and high-income levels was observed for intention to quit. The effect of education on high consumption and dependence was mainly found in smokers with high income.

CONCLUSION

Increased effort to combat social differences in smoking behaviour is needed. Implementation of smoking cessation programmes with high reach among low socioeconomic groups is recommended.

Decreasing educational differences in mortality over 40 years: evidence from the Turin Longitudinal Study (Italy)

BACKGROUND

Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries.

METHODS

In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality.

RESULTS

Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05).

CONCLUSIONS

Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries.

Socioeconomic inequalities in smoking cessation in 11 European countries from 1987 to 2012

BACKGROUND

During the 1990s, inequalities in smoking prevalence by socioeconomic status (SES) have widened in Europe. Since then, many tobacco control policies have been implemented. Yet, European overviews of recent trends in smoking inequalities are lacking. This paper aims to provide an overview of long-term trends of socioeconomic inequalities in smoking cessation in Europe.

METHODS

We used data for 11 countries taken from Eurobarometer surveys from 1987 to 1995 and 2002-2012, with a total study sample of 63 737 respondents. We performed multilevel logistic regression to model associations of the quit ratio (proportion former smokers of ever smokers) with SES, measured by education and occupation separately, with adjustments for age, sex and time.

RESULTS

We found a significant, positive association for education and occupation with the quit ratio. The strength of the association decreased slightly from 1987 to 1995 and increased again from 2002 to 2012. Inequalities increased between the two periods in most countries and decreased in only one country. While in 1987-1995, the quit ratio increased among all SES groups and most strongly among the low SES group, in 2002-2012 it increased only among the high-education group (OR=1.38, 95% CI 1.02 to 1.87), and non-manual occupation group (OR=1.59, 95% CI 1.19 to 2.12).

CONCLUSIONS

Socioeconomic inequalities in smoking cessation rates have strongly increased since the 1990s and during the 2000s. This suggests that the tobacco control policies implemented during the 2000s have not been able to counter the trend in increasing inequalities.

Evolution of socioeconomic inequalities in smoking: results from the Portuguese national health interview surveys

BACKGROUND

Southern European countries were traditionally characterized by a higher prevalence of smoking among high socioeconomic groups. Though, recent studies show a reversal of inequalities in Italy and Spain, for example. We investigated whether this evolution also applied to Portugal by describing the evolution of socioeconomic inequalities in smoking between 1987 and 2006.

METHODS

We used data from the four Portuguese national health interview surveys (N = 120,140) carried out so far. Socioeconomic status was measured by the educational and income levels of respondents. Socioeconomic inequalities were measured through Odds Ratios (OR), Relative Inequality Indexes (RII), and Concentration Indexes (CI) on being current, ever, and former smoker, adjusting for sex and age. Analyses were performed separately for men and women, and for different birth cohorts.

RESULTS

Among men, smoking was initially more concentrated in high-socioeconomic status individuals (RII = 0.84, 95% Confidence Intervals [95% CI] 0.76-0.93, 1987) but this pattern reversed in the last survey (RII = 1.49, 95% CI 1.34-1.65, 2005/6). Indeed, higher cessation rates were observed among high-socioeconomic groups among all respondents (RII = 0.89, 95% CI 0.84-0.95), coupled with higher initiation rates among the worse-off in younger cohorts (RII = 1.18, 95% CI 1.05-1.31, for youngest generation, 2005/6). Among women, the richer and more educated smoked more in all surveys (RII = 0.21, 95% CI 0.16-0.27, 2005/6), despite being also more likely to quit (RII = 0.41, 95% CI 0.30-0.55). The pattern among women evolved towards a reduction of inequality, which however remained favourable to the worse-off.

CONCLUSIONS

Inequalities have been increasingly unfavourable to the worse-off in Portugal, although better-off women are still more likely to smoke. Worrisome inequality trends have been observed among the youngest generations, which call for the rapid implementation of equity-oriented tobacco control policies.

Generation shifts in smoking over 20 years in two Dutch population-based cohorts aged 20-100 years

BACKGROUND

Younger and older generations may differ substantially in their lifetime smoking habits, which may result in generation-specific health challenges. We aimed to quantify generation shifts in smoking over a period of 25 years.

METHODS

We used the Doetinchem Cohort Study (baseline 1987-1991; 7768 individuals; 20-60 years; follow-up 1993-2012) and the Longitudinal Aging Study Amsterdam (baseline 1992-1993; 3017 individuals; 55-85 years; follow-up 1995-2009). Generation shifts were studied between 10-year generations (age range: 20-100 years). Generation shifts were examined graphically and by using logistic random effect models for men and women.

RESULTS

Among men, significant generation shifts in current smoking were found between two non-successive generations: for instance men in their 40s at baseline smoked much more than men in their 40s at follow-up (33.6% vs. 23.1%, p < 0.05). Among women, the most recently born generation showed a favourable significant generation shift in current smoking (-7.3%) and ever smoking (-10.1%). For all other generations, the prevalence of ever smoking among women was significantly higher in every more recently born generation, whereas no other generation shifts were observed for current smoking. The unfavourable generation shifts were mainly found among the lower educated.

CONCLUSIONS

The future burden of disease due to smoking is expected to be reduced among men, but not yet among women. Educational differences in smoking-related health problems are expected to increase.

Trends in tobacco consumption in three different birth cohorts of elderly of São Paulo, Brazil

BACKGROUND

The effects of birth cohorts reflect the historical differences in physical and social environments. The objectives of the present study were to describe the tobacco consumption and to evaluate the behavioral trends with respect to smoking in three different birth cohorts of a population-based sample of elderly individuals.

METHODS

A series of three cross-sectional studies conducted with elderly individuals of 60-64 years of age interviewed in 2000 (birth cohort 1936-1940; n=427), 2006 (birth cohort 1942-1946; n=298) and 2011 (birth cohort 1947-1951; n=355) in a population-based sample from the city of São Paulo, Brazil. The interviewees were participating in a prospective cohort study entitled Health, Well-Being and Aging (Saúde, Bem-Estar e Envelhecimento [SABE]). Data on tobacco consumption were self-reported and interviewees were then classified as never smokers, former smokers or current smokers. Linear model for categorical data was used to test differences on tobacco consumption between three birth elderly cohorts.

FINDINGS

Men were more likely than women to be smokers. Being evangelical and having more schooling constituted protective factors against smoking. Regarding trends, the tobacco consumption of the men did not change in any of the three cohorts studied (p=0.7454), whereas there was an increase in the number of women smokers, principally former smokers, over the periods evaluated (p=0.0189).

CONCLUSIONS

These results suggest that the anti-smoking policies implemented in Brazil were effective in women of this age group; however, different prevention strategies are required to target elderly men.

Addressing population health and health inequalities: the role of fundamental causes

OBJECTIVES

As a case study of the impact of universal versus targeted interventions on population health and health inequalities, we used simulations to examine (1) whether universal or targeted manipulations of collective efficacy better reduced population-level rates and racial/ethnic inequalities in violent victimization; and (2) whether experiments reduced disparities without addressing fundamental causes.

METHODS

We applied agent-based simulation techniques to the specific example of an intervention on neighborhood collective efficacy to reduce population-level rates and racial/ethnic inequalities in violent victimization. The agent population consisted of 4000 individuals aged 18 years and older with sociodemographic characteristics assigned to match distributions of the adult population in New York City according to the 2000 U.S. Census.

RESULTS

Universal experiments reduced rates of victimization more than targeted experiments. However, neither experiment reduced inequalities. To reduce inequalities, it was necessary to eliminate racial/ethnic residential segregation.

CONCLUSIONS

These simulations support the use of universal intervention but suggest that it is not possible to address inequalities in health without first addressing fundamental causes.

Socioeconomic inequalities in smoking habits are still increasing in Italy

Background

Socioeconomic inequalities in smoking habits have stabilized in many Western countries. This study aimed at evaluating whether socioeconomic disparities in smoking habits are still enlarging in Italy and at comparing the impact of education and occupation.

Methods

In the frame of the GEIRD study (Gene Environment Interactions in Respiratory Diseases) 10,494 subjects, randomly selected from the general population aged 20–44 years in seven Italian centres, answered a screening questionnaire between 2007 and 2010 (response percentage = 57.2%). In four centres a repeated cross-sectional survey was performed: smoking prevalence recorded in GEIRD was compared with prevalence recorded between 1998 and 2000 in the Italian Study of Asthma in Young Adults (ISAYA).

Results

Current smoking was twice as prevalent in people with a primary/secondary school certificate (40-43%) compared with people with an academic degree (20%), and among unemployed and workmen (39%) compared with managers and clerks (20-22%). In multivariable analysis smoking habits were more affected by education level than by occupation. From the first to the second survey the prevalence of ever smokers markedly decreased among housewives, managers, businessmen and free-lancers, while ever smoking became even more common among unemployed (time-occupation interaction: p = 0.047). At variance, the increasing trend in smoking cessation was not modified by occupation.

Conclusion

Smoking prevalence has declined in Italy during the last decade among the higher socioeconomic classes, but not among the lower. This enlarging socioeconomic inequality mainly reflects a different trend in smoking initiation.

The national "smoking cessation clinics" program in the republic of Korea: socioeconomic status and age matter

BACKGROUND

Between 1998-2009 South Korea experienced significant progress in reducing the male smoking rate from 66.3% to 46.9%. As part of a significant government effort in the area of smoking cessation intervention, the Korean government implemented the national "Smoking Cessation Clinics (SCC) " program in 2004.

MATERIALS AND METHODS

Data covered 804,334 adult male smokers participating in SCC program at 253 public health centers between 2006-2009. We examined participant cessation rates with the SCC program, their characteristics and program intervention components using health insurance status as a socioeconomic status (SES) indicator. Multivariate logistic regression analyses were performed correcting for intra-class correlations within public health centers.

RESULTS

The overall 6-month quit rate was high (46.8%). Higher odds of smoking cessation were positively associated with higher levels of behavioral counseling sessions, but not nicotine replacement therapy (NRT). Cessation rates were lower for Medicaid participants than for regular health insurance participants. Disadvantaged younger smokers were less likely to participate in the program. Older smokers were more likely to quit regardless of SES. Stress was cited as major reason for failure.

CONCLUSIONS

SES inequalities across different age groups exist in smoking cessation among Korean adult male smokers. There is a need for intervention programs specifically targeting sub-populations of SES by different age groups.

Personal factors associated with smoking among marginalized and disadvantaged youth in Japan. A strong relationship between smoking and convenience store use

Background

A national survey in Japan reported that the prevalence of smoking among high school students has sharply decreased in recent years. However, the survey only considered students who attended regular high schools (RHSs), and Japan offers part-time high schools (PHSs) that are often attended by academically and socioeconomically disadvantaged youth.

Purpose

Therefore, we examined the smoking prevalence and smoking-related factors among PHS students.

Method

A self-administered questionnaire-based survey was conducted at six PHSs. The subjects included 540 enrolled students aged 15 to 18 years. The questionnaire included items on smoking status, smokers in the family, frequency of convenience store use, lifestyle behaviors, and health awareness. Logistic regression analysis was used to identify factors that were significantly associated with smoking.

Results

A total of 45.6 % of students had smoking experience, and 29.3 % were smokers. For males and females, the smoking prevalence was about 3 and 7–12 times higher, respectively, than that reported in the national survey. The factors found to be significantly associated with smoking included having a smoker in the family, experience with drinking alcohol, and using convenience store daily (odds ratio [OR] = 12.5) or sometimes (OR = 3.63). There was a significant dose–response relationship between smoking and convenience store use.

Conclusion

The smoking prevalence among PHS students was remarkably higher than that among RHS students. These findings suggest that marginalized and disadvantaged youth should be targeted for tobacco control, and intervention is needed to protect youth from tobacco sales and advertising at convenience stores.

[Does the population approach increase health inequality? Vulnerable population approach as an alternative strategy]

The population approach is well recognized as an effective strategy to improve population health, as well as the population-at-risk approach. It aims to decrease risk exposure of the total population through a change of contextual conditions. However, the population approach has the possibility of increasing health inequality because of variation in the effectiveness of the strategy in accordance with the risk exposure. This paper proposes the "vulnerable population approach" as an alternative and supplemental strategy. It aims to decrease health inequalities between socially defined groups, by shifting the distribution of a lower level of risk exposure of the groups through changes in social and environmental conditions that make groups at higher risk. No interventional approach can be singly applied to all health problems. To improve population health, it is important to select the most effective strategy among the three approaches, considering their advantages and limitations, and to adopt a suitable combination of different approaches.

Socioeconomic inequalities in youth smoking in Brazil

OBJECTIVE

The contribution of smoking to socioeconomic inequalities in health is increasing worldwide, including in Brazil. Youth smoking may play an important role in the increasing social inequalities related to smoking. This study investigates social determinants of smoking among 15-year-old to 19-year-old individuals.

DESIGN

Cross-sectional study.

SETTING

The study uses data of 3536 participants aged 15-19 years of age of the Global Adult Tobacco Survey (GATS) and the National Household Sample Survey (Pesquisa Nacional por Amostragem de Domicilio, PNAD) obtained from household interviews. Smoking was defined as currently smoking tobacco products, regardless of frequency. Household socioeconomic indicators included per capita income, the educational level and sex of the head of the household, the presence of smoking restrictions and the number of smokers (excluding adolescents). Adolescent social factors included years of delaying school and social status (full-time student, working, and neither working nor studying). The hierarchical logistic regression analysis considered the effect of the complex sampling design.

RESULTS

From 3536 participants, 6.2% were smokers (95% CI 5.4 to 7.1). More men than women had the habit of smoking (7.2%; 5.9 to 8.6 vs 3.6%; 2.7 to 4.6). The likelihood of smoking was significantly greater for men and older teens. There was an upward trend in the OR of smoking according to the number of smokers in the house. Adolescents living in households with no smoking restrictions had a greater likelihood of being smokers. OR of smoking rose as the number of years of delaying school increased, being about three times greater among adolescents who were working and five times greater among those who were neither studying nor working.

CONCLUSIONS

Results demonstrate that socioeconomic inequality in smoking is established at younger ages and that school delay as well as school abandonment may contribute to increased smoking-related inequalities. Smoking restrictions at home were protective against adolescents becoming smokers. Living with other smokers was a strong predictor of adolescents becoming smokers.

Decennial trends of social differences in smoking habits in Italy: a 30-year update

PURPOSE

To update educational inequalities in smoking in Italy up to 2009, with an in-depth analysis of female prevalence.

METHODS

Data from 15 national health surveys (1980, 1983, 1986-1987, 1990, 1994, 1999-2003, 2005-2009) were analyzed. The overall sample size was representative of the population older than 25 years of age (3,300,000 men and 3,620,000 women). Main measures smoking prevalence rates standardized to the 2,000 European population, prevalence ratios by educational level (high: university degree or high school diploma; low: primary or middle school diploma), area (north, center, south and islands), and age-group (25-44, 45-59, >=60 years). Trends in tobacco prevalence were also analyzed with a multivariate approach using the negative binomial distribution.

RESULTS

Although male prevalence steadily declined of about 2% annually from 56.1% in 1980 to 30.2% in 2009, educational inequalities slightly widened, recording in 2009 a 53% higher prevalence in men with low educational level compared to graduates. Even though female prevalence stalled around 18% in the last three decades, this was the result of opposite trends by educational group. In fact, highly educated women, with the highest prevalence during 1980s, decreased their tobacco use, determining a reversal similar to men in educational inequalities in smoking. This reversal occurred from the 1980s onwards with a time gradient starting from north to south and from younger to older women.

CONCLUSION

To achieve a fairer reduction in smoking habits, tobacco control policies focusing on lower social groups are needed.

Predictors of success for smoking cessation at the workplace: a longitudinal study

BACKGROUND

The effectiveness of worksite interventions to reduce smoking is debatable.

OBJECTIVES

A comprehensive smoking cessation intervention was implemented in a community of more than 17,000 employees at three different health care companies. The primary endpoint was abstinence at 24 months (self-reported and confirmed by exhaled carbon monoxide ≤ 6 parts per million). Predictors of long-term abstinence were analysed by multivariable regression analysis.

METHODS

The study was designed as an investigator-initiated and investigator-driven, open, multicentre, cohort study; 887 smokers were enrolled in the programme. The intervention included intensive individual counselling as well as nicotine replacement and/or bupropion according to individual preferences. Re-interventions for relapse were offered during the 24-month follow-up.

RESULTS

The abstinence rate was 37% at 24 months and did not differ among the various medication groups (p > 0.05 for all). Predictors of successful cessation were higher age (odds ratio, OR 1.47, 95% confidence interval, CI 1.08-2.00, p < 0.01), breathlessness on exertion (OR 2.26, 95% CI 1.1-4.9, p = 0.03), and a higher educational level (OR 1.81, 95% CI 1.06-3.09, p = 0.03). Higher Fagerström (OR 0.76, 95% CI 0.59-0.97, p < 0.01) and craving scores (OR 0.75, 95% CI 0.63-0.89, p < 0.01), chronic sputum production (OR 0.52, 95% CI 0.31-0.87, p = 0.01) and use of antidepressants (OR 0.54, 95% CI 0.32-0.91, p = 0.02) were associated with ongoing smoking.

CONCLUSION

A comprehensive smoking cessation intervention at the workplace achieves high, stable, long-term abstinence rates. Elderly, well-educated employees with breathlessness on exertion have higher odds of quitting smoking. In contrast, those with high physical dependency and more intense craving, and those reporting use of antidepressant medication or sputum production have poorer chances to quit.

Men's health: a population-based study on social inequalities

This study evaluates social inequalities in health according to level of schooling in the male population. This was a cross-sectional, population-based study with a sample of 449 men ranging from 20 to 59 years of age and living in Campinas, São Paulo State, Brazil. The chi-square test was used to verify associations, and a Poisson regression model was used to estimate crude and adjusted prevalence ratios. Men with less schooling showed higher rates of alcohol consumption and dependence, smoking, sedentary lifestyle during leisure time, and less healthy eating habits, in addition to higher prevalence of bad or very bad self-rated health, at least one chronic disease, hypertension, and other health problems. No differences were detected between the two schooling strata in terms of use of health services, except for dental services. The findings point to social inequality in health-related behaviors and in some health status indicators. However, possible equity was observed in the use of nearly all types of health services.

Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey

Background

Widening of socioeconomic status (SES) inequalities in smoking prevalence has occurred in several Western countries from the mid 1970’s onwards. However, little is known about a widening of SES inequalities in smoking consumption, initiation and cessation.

Methods

Repeated cross-sectional population surveys from 2001 to 2008 (n ≈ 18,000 per year) were used to examine changes in smoking prevalence, smoking consumption (number of cigarettes per day), initiation ratios (ratio of ever smokers to all respondents), and quit ratios (ratio of former smokers to ever smokers) in the Netherlands. Education level and income level were used as indicators of SES and results were reported separately for men and women.

Results

Lower educated respondents were significantly more likely to be smokers, smoked more cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated respondents. Income inequalities were smaller than educational inequalities and were not all significant, but were in the same direction as educational inequalities. Among women, educational inequalities widened significantly between 2001 and 2008 for smoking prevalence, smoking initiation, and smoking cessation. Among low educated women, smoking prevalence remained stable between 2001 and 2008 because both the initiation and quit ratio increased significantly. Among moderate and high educated women, smoking prevalence decreased significantly because initiation ratios remained constant, while quit ratios increased significantly. Among men, educational inequalities widened significantly between 2001 and 2008 for smoking consumption only.

Conclusions

While inequalities in smoking prevalence were stable among Dutch men, they increased among women, due to widening inequalities in both smoking cessation and initiation. Both components should be addressed in equity-oriented tobacco control policies.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

INTRODUCTION AND AIMS

Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking.

DESIGN AND METHODS

A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation.

RESULTS

After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0-12.8%) than their counterparts in more advantaged neighbourhoods (20.7-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (P ≤ 0.001) and in 2009 it was 0.260 (P ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% credible intervals (CrI) 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98, 95% CrI 1.48-2.66).

CONCLUSION

Fundamentally, social and economic inequalities at the neighbourhood and individual levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded and targeted tobacco control efforts and equity-based policies that address the social and economic determinants of smoking.

Socioeconomic differences in tobacco smoking in Italy: is there an interaction between variables?

OBJECTIVES

To assess the influence of sociodemographic factors on smoking habits in Italy and if an interaction exists between these variables.

METHODS

Data from the national survey "Health Conditions and Healthcare Services Use" in 2005 were used. The independent association between tobacco smoking and sociodemographical variables was assessed using logistic regression analysis. Interactions between variables were investigated calculating the synergism index (SI).

RESULTS

Sample population consists of 109.829 subjects (over 15 years). 21.9% are current and 21.8% are former smokers. Current smokers are mostly 45-54-years old males, from Central Italy, unemployed, divorced or separated but having a good health status without chronic medical conditions. Ever smokers are mostly 45-54 years old males, from Northeast Italy, unemployed, with chronic conditions. People with a university degree and with a good household income have the lowest OR for both conditions. A synergistic effect was found between marital status and educational level (for ever smokers SI = 1.96; for current smokers SI = 1.67).

CONCLUSIONS

Smoking is prevalent in lower socioeconomic groups and there is the strong need to increase social, economic and cultural capital in order to reduce it.

Socioeconomic Indicators Associated with Initiation and Cessation of Smoking among Women in Seoul

Background

While smoking prevalence in Korean men has been decreasing, it is increasing in Korean women. Little is known about women's smoking inequalities in Korea. This study was conducted to investigate the association of socioeconomic indicators with the initiation and cessation of smoking among Korean women.

Methods

This was a cross-sectional study on 9,089 women aged 25-64 years from the 2008 Seoul Community Health Survey. The data on smoking and socioeconomic status were obtained through face-to-face interviews. Smoking initiation rate was defined as the proportion of the individuals who had started smoking at least one cigarette among all subjects. Smoking cessation rate was calculated by dividing the number of individuals who had quit smoking by the number of ever smokers. Education level, total family income and occupation were investigated as socioeconomic indicators.

Results

Education level was significantly associated with both initiation and cessation of smoking. Lower educated women had a higher likelihood of smoking initiation (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.17 to 2.51) but lower likelihood of smoking cessation (OR, 0.38; 95% CI, 0.22 to 0.66) than higher educated women. Smoking initiation rate was higher in manual workers (OR, 1.65; 95% CI, 1.20 to 2.27) than in non-manual workers. However, there were no significant differences of both initiation and cessation of smoking according to total household income.

Conclusion

This study shows that there are smoking inequalities among Korean women. It is thought that education level and occupation are important determinants of women's smoking status.

Regional surveillance of social and geographic inequalities in smoking: the case of Montréal, Canada

Surveillance of social inequalities in health is a platform for action. We examined the trends in smoking behaviours (current and ever smoking, quit ratios) according to education and place of residence and we quantified the observed inequalities. Data were from repeated cross-sectional surveys (2003-2009) of Montreal (Canada) residents ≥15 years (n=12,053). Trends in smoking behaviours according to education were measured with logistic and log-binomial regressions. Spatial distribution of smoking behaviours across local areas was assessed with Morans' Index. Observed inequalities were quantified with prevalence ratio and difference, population attributable risk, and slope index of inequality. Results showed that ever smoking rose among low-educated individuals. Among their high-educated fellow-citizens, current smoking decreased and quit ratios increased. Adverse smoking behaviours (current and ever smoking) were clustered in south-central areas. We conclude that smoking inequalities in Montreal are growing. We thus encourage a closer monitoring of smoking social differentials.

Does non-employment contribute to the health disadvantage among lone mothers in Britain, Italy and Sweden? Synergy effects and the meaning of family policy

This study analyses self-rated health and non-employment and potential synergy effects among lone and couple mothers aged 25-59 in Britain, Sweden and Italy, representing different family policy categories using data from national surveys (2000-2005). Synergy effects on health were calculated by synergy index. Non-employment only marginally contributed to the excess risk of poor health among lone mothers but there were synergy effects between lone motherhood and non-employment in all three countries, producing a higher risk of poor health than would be expected from a simple addition of these exposures. Results are discussed in relation to the different family policy and living contexts.

Nicotine dependence and psychological distress: outcomes and clinical implications in smoking cessation

Nicotine dependence is characteristically a chronic and relapsing disease. Although 75%-85% of smokers would like to quit, and one-third make at least three serious lifetime attempts, less than 50% of smokers succeed in stopping before the age of 60. Relevant and complex factors contributing to sustained cigarette consumption, and strongly implicated in the clinical management of smokers, are the level of nicotine dependence and psychological distress. In this review of the literature, these two factors will be examined in detail to show how they may affect smoking cessation outcome and to encourage clinicians to assess patients so they can offer tailored support in quitting smoking.

Widening inequalities in smoking initiation and cessation patterns: a cohort and gender analysis in France

AIMS

This study investigates the evolution of educational inequalities in smoking initiation and cessation in France according to gender and birth cohort.

METHODS

We used a 2005 nationwide survey comprising 25,239 subjects aged 18-75 years. Three cohort groups were defined (born 1930-1945, 1946-1965 or 1966-1987). We compared their smoking histories until age 40 years with time-discrete logistic regressions. Educational differences in initiation and cessation were quantified using odds ratios and relative indices of inequality (RII), and the gender gap using odds ratios (gender ratios).

RESULTS

For smoking initiation, in the oldest cohorts, no educational gradient appeared in men, but there was a positive gradient in women (RII=0.19); in the middle cohorts, a negative gradient emerged in men (RII=1.55), while the positive gradient reduced in women (RII=0.74); in the youngest cohorts, there was a strengthening of the negative gradient in men (RII=2.72), and the emergence of a negative gradient for women (RII=1.86). The gender ratio narrowed from the oldest cohorts (3.23) to the youngest (1.09), and diminished with increasing educational level within each cohort. For smoking cessation, the educational gradients were negative in both genders, with wider gaps in the youngest cohorts, and gender ratios below 1 reflecting more marked cessation dynamics in women.

CONCLUSION

Women are at an earlier stage in the tobacco epidemic than men for initiation and at a later stage for cessation and social inequalities are widening. We believe that they will not decrease unless gender and the psycho-social aspects of smoking are considered in prevention campaigns.

Socioeconomic differences in the effectiveness of the removal of the "light" descriptor on cigarette packs: findings from the International Tobacco Control (ITC) Thailand Survey

Many smokers incorrectly believe that “light” cigarettes are less harmful than regular cigarettes. To address this problem, many countries have banned “light” or “mild” brand descriptors on cigarette packs. Our objective was to assess whether beliefs about “light” cigarettes changed following the 2007 removal of these brand descriptors in Thailand and, if a change occurred, the extent to which it differed by socioeconomic status. Data were from waves 2 (2006), 3 (2008), and 4 (2009) of the International Tobacco Control (ITC) Thailand Survey of adult smokers in Thailand. The results showed that, following the introduction of the ban, there was an overall decline in the two beliefs that “light” cigarettes are less harmful and smoother than regular cigarettes. The decline in the “less harmful” belief was considerably steeper in lower income and education groups. However, there was no evidence that the rate of decline in the “smoother” belief varied by income or education. Removing the “light” brand descriptor from cigarette packs should thus be viewed not only as a means to address the problem of smokers’ incorrect beliefs about “light” cigarettes, but also as a factor that can potentially reduce socioeconomic disparities in smoking-related misconceptions.