Area-level characteristics and smoking in women

Correlates of appropriate disposal of children's stools in Malawi: a multilevel analysis

BACKGROUND

Management of children's stools is an important aspect of achieving open defecation free communities and reduction of diarrhea. However, information regarding individual- and community- level factors associated with safe child stool disposal in Malawi is limited. The current study aimed to assess the prevalence of safe child stool disposal and the associated individual- and community- level factors in Malawi.

METHODS

The cross-sectional study used data from the 2015-16 Malawi Demographic Health Survey in which 6326 children aged under 2 years, nested within 850 communities, were analyzed. Individual- and community- level factors were tested for association with safe child stool disposal practice using multilevel logistic regression models.

RESULTS

Results revealed that 85.6% of the women reported to have safely disposed of their children's stools. Women from households with improved sanitation had 36.0% greater odds of safely disposing of their children's stools compared with those from households with unimproved sanitation [(adjusted odds ratio (aOR): 1.36; 95% confidence interval (CI): 1.12-1.65). Further, women from communities with a middle (aOR: 1.62; 95% CI: 1.18-2.21) and high (aOR: 1.45; 95% CI: 1.14-1.84) percentage of educated women were more likely to have their children's stools safely disposed of than those from communities with a low percentage of educated women. Children's age, media exposure, and region were significantly associated with safe stool disposal.

CONCLUSION

Both Individual- and community-level factors were revealed to be important factors for child stool disposal. Public health strategies designed to promote sanitation/safe child stools disposal need to conduct thorough community assessments to identify community-specific needs/barriers. Additionally, public health practitioners should take into consideration the geographical and wealth inequalities when designing programs aimed to improve safe child stood disposal.

A commercially available crime index may be a reliable alternative to actual census-tract crime in an urban area

Health research on the effects of crime has been hampered by a lack of small-scale, reliable crime data. Our objective is to assess the accuracy of a set of commercially available crime indices for use in health research. The 2016 release of Applied Geographic Solutions' (AGS) crime indices are based on data from 2010 to 2014 and provide tract-level information on crime. We use crime rates for 1069 tracts of the Los Angeles Police Department (LAPD) jurisdiction for the same years to assess (1) Spearman Correlations of major crime categories, and (2) accuracy of AGS indices in predicting falling above/below the median and into the highest/lowest quartile of LAPD crime. We also test if adding variables from the American Community Survey (ACS) to regression analyses can help to reduce measurement bias. We found that five of ten AGS indices correlated moderately well with LAPD crime. In unadjusted regressions, robbery, homicide, aggravated assault, motor-vehicle theft and personal crime achieved c-statistics from 0.81 to 0.90. C-statistics improved up to 0.13 points after adding ACS variables. Some AGS crime indices may be reliable proxies for crime in an urban area. The AGS index for total crime, most commonly used in prior research, performed poorly.

Decomposition of passive smoking inequality in Iranian children and adolescents: the CASPIAN-V Study

To investigate the socioeconomic inequality in passive smoking in Iranian children and adolescents. Through a multistage random cluster sampling method, a representative sample of 14,400 school students, aged 6-18 years, were enrolled from urban and rural areas of 30 provinces of Iran. Using a non-linear principal component analysis (NLPCA), the correlated variables were summarized as socioeconomic status (SES). Normalized concentration index (NCI) was used to measure inequality in passive smoking at national and regional SES levels. We decomposed total socioeconomic inequality in passive smoking into explanatory variables to identify the main contributors of inequality in passive smoking in the population studied. Data of 12,327 students and parents were complete for the current study. The response rate was 85.6% (50.9% boys, 71.2% urban residents). About 44% of Iranian students were exposed to passive smoking. The NCI for passive smoking at a national level was - 0.043 (95% confidence interval - 0.035, - 0.012), indicating that passive smoking was more concentrated among poorer children and adolescents. This inequality was statistically significant at a national level and in all regions except for regions with lower middle- and lowest SES levels. Considering the decomposition analysis, the household SES (63%), mothers' educational level (37%), fathers' educational level (29%), and school type (18%) made the largest positive contribution to inequality in passive smoking of children and adolescents. Passive smoking was distributed unequally among Iranian children and adolescents; it was more concentrated among socioeconomically disadvantaged families. Public health policies attentions should be given to reduce passive smoking among low SES children and adolescents living with illiterate or low-educated parents.

The Influence of Tobacco Retailer Density and Poverty on Tobacco Use in a Densely Populated Urban Environment

OBJECTIVES

Researchers have identified associations between neighborhood-level factors (eg, income level, tobacco retailer density) and smoking behavior, but few studies have assessed these factors in urban environments. We explored the effect of tobacco retailer density, neighborhood poverty, and housing type (multiunit and public) on smoking in a large urban environment (New York City).

METHODS

We used data on smoking prevalence and individual sociodemographic characteristics from the 2011-2013 New York City Community Health Survey, data on tobacco retailers from the 2012 New York City Department of Consumer Affairs, data on neighborhood sociodemographic characteristics and population density from the 2009-2013 American Community Survey, and data on multiunit and public housing from the 2012 New York City Primary Land Use Tax Lot Output data set. We used aggregate neighborhood-level variables and ordinary least squares regression, geographic weighted regression, and multilevel models to assess the effects of tobacco retailer density and neighborhood poverty on smoking prevalence, adjusting for sociodemographic characteristics (age, sex, race/ethnicity, and education) and neighborhood population density. We also assessed interactions between tobacco retailer density and poverty and each housing type on smoking.

RESULTS

Neighborhood poverty positively and significantly modified the association between tobacco retailer density and prevalence of neighborhood smoking ( β = 0.003, P = .01) when we controlled for population density, sociodemographic characteristics, and types of housing. Neighborhood poverty was positively associated with the prevalence of individual smoking ( β = 0.0099, P < .001) when we adjusted for population density, sociodemographic characteristics, and type of housing.

CONCLUSION

More research is needed to determine all the environmental factors associated with smoking prevalence in a densely populated urban environment.

Neighbourhood safety and smoking in population subgroups: The HELIUS study

This study examines the associations between neighbourhood safety and three types of smoking behaviour, and whether these associations differ by sex, age, ethnicity and individual-level socio-economic position. Baseline data (2011-2015) from the The HEalthy LIfe in an Urban Setting (HELIUS) study (Amsterdam, the Netherlands) were used. Smoking behaviour was based on self-report. Heavy smoking was defined as smoking ≥10 cigarettes per day. Nicotine dependence was assessed using the Fagerström questionnaire. Geographic Information System techniques were used to construct local residential areas and to examine neighbourhood safety for these areas using micro-scale environmental data. Multilevel logistic regression analyses with 6-digit zip code area as a second level were used to assess the association between neighbourhood safety and smoking. In our study sample of 22,728 participants (18-70 years), 24.0% were current smokers, 13.7% were heavy smokers and 8.1% were nicotine dependent individuals. Higher levels of neighbourhood safety were significantly associated with less heavy smoking (OR = 0.88, 95% CI = 0.78-0.99) and less nicotine dependence (OR = 0.81, 95% CI = 0.69-0.95), but not with less current smoking (OR = 1.01, 95% CI = 0.91-1.11). The associations between neighbourhood safety and the three types of smoking behaviour varied by ethnicity. For instance, higher levels of neighbourhood safety were associated with less current smoking in participants of African Surinamese origin (OR = 0.71, 95% CI = 0.57-0.89), but not in those of Dutch (OR = 1.13, 95% CI = 0.91-1.39), South-Asian Surinamese (OR = 1.22, 95% CI = 0.95-1.55), Turkish (OR = 1.08, 95% CI = 0.84-1.38), Moroccan (OR = 1.53, 95% CI = 1.12-2.10) or Ghanaian (OR = 1.18, 95% CI = 0.47-2.94) origin. Policies that improve neighbourhood safety potentially contribute to less heavy smoking and nicotine dependence.

The intention to quit smoking

Purpose

From the perspective of developing countries, studies regarding the behavioral effects of quitting tobacco consumption on emerging psychological determinants are limited. The purpose of this paper is to examine the influence of emotional intelligence (EI), social norms, susceptibility and self-efficacy on the behavioral effects of quitting tobacco consumption among young smokers in developing countries.

Design/methodology/approach

By reviewing existing literature, this study developed a conceptual model to test the influences of significant psychological determinants in regards to a young smoker’s intention to quit smoking. Accordingly, a survey instrument was designed to collect data from young smokers in Bangladesh using the convenience sampling method. A total of 500 self-administered questionnaires were distributed, out of which only 400 questionnaires were used in final data analysis. This study applied partial least square structural equation modeling (PLS-SEM) to test the proposed model.

Findings

Perceived EI, perceived social norms and perceived susceptibility were found to have significant direct positive effects on intention to quit smoking. Perceived susceptibility and perceived self-efficacy were observed to have moderating effects on intention to quit smoking through perceived EI and perceived social norms respectively. However, perceived self-efficacy was not found to have any significant direct effect on intention to quit smoking.

Originality/value

This is the first study of its kind which combined EI, susceptibility, self-efficacy, and social norms in one theoretical framework to explain a young smoker’s intention to quit smoking. Also, in the context of Bangladesh and similar developing countries, there are no such studies which used the psychological components investigated in this study to predict a young smoker’s intention to quit smoking. Thus, the findings bring us closer to the goal of a tobacco-free society by allowing policy makers, NGOs, broader communities, and ultimately individual citizens to understand the psychological predictors of quitting tobacco consumption among young smokers in developing countries.

Cross-sectional and longitudinal associations of neighbourhood social environment and smoking behaviour: the multiethnic study of atherosclerosis

BACKGROUND

Social features of neighbourhood environments may influence smoking by creating a stressful environment or by buffering stress through social cohesion. However, the association of the overall neighbourhood social environment (NSE) with smoking, and the association of specific neighbourhood social factors with change in smoking behaviour over time, has rarely been examined.

METHODS

This study included 5856 adults aged 45-84 years from the Multi-Ethnic Study of Atherosclerosis (2000-2012, average follow-up: 7.8 years). Outcomes included current smoking status and smoking intensity (average number of cigarettes smoked per day among baseline smokers). NSE was assessed as a composite score composed of aesthetic quality, safety and social cohesion scales (derived from neighbourhood surveys). Generalised linear mixed models evaluated the association of baseline NSE (composite score and individual scales) with current smoking (modified Poisson models) and smoking intensity (negative binomial models) cross-sectionally and longitudinally.

RESULTS

Each SD increase in baseline NSE composite score was associated with 13% lower prevalence of smoking at baseline (adjusted prevalence ratio (aPR) 0.87 (95% CI 0.78 to 0.98). Neighbourhood safety and aesthetic quality were similarly associated with lower smoking prevalence (aPR 0.87 (0.78 to 0.97) and aPR 0.87 (0.77 to 0.99), respectively) but the association with social cohesion was weaker or null. No significant associations were observed for smoking intensity among baseline smokers. Baseline NSE was not associated with changes in smoking risk or intensity over time.

CONCLUSIONS

Results suggest that neighbourhood social context influences whether older adults smoke, but does not promote smoking cessation or reduction over time.

Neighborhood deprivation and cardiovascular disease risk factors: Protective and harmful effects

AIMS

To determine whether neighborhood-level deprivation is independently associated with cardiovascular disease (CVD) health behaviors/risk factors in the Swedish population.

METHODS

Pooled cross-sectional data, Swedish Annual Level of Living Survey (1996-2000) linked with indicators of neighborhood-level (i.e. Small Area Market Statistics areas) deprivation (1997), to examine the association between neighborhood-level deprivation and individual-level smoking, physical inactivity, obesity, diabetes, and hypertension among women and men, aged 25-64 (n = 18,081). Data were analyzed with a series of logistic regression models that adjusted for individual-level age, gender, marital status, immigration status, urbanization, and a comprehensive measure of socioeconomic status (SES). Interactions were tested to determine whether neighborhood effects varied by SES or length of neighborhood exposure.

RESULTS

Living in a neighborhood with low deprivation was protective (i.e. lower odds) for smoking, while living in a neighborhood with high deprivation was harmful (i.e. higher odds) for smoking, physical inactivity, and obesity (compared with living in a neighborhood with moderate deprivation). These associations were significant after adjustment for individual-level characteristics. There was no evidence that the neighborhood deprivation associations varied by individual-level SES or length of neighborhood exposure.

CONCLUSIONS

Neighborhood-level deprivation exerted important protective and harmful associations with health behaviors/risk factors related to CVD. The significance to public health is substantial because of the number of persons at risk as well as the serious health consequences of CVD. These results suggest that interventions focusing on changing contextual aspects of neighborhoods, in addition to changing individual behaviors, may have a greater impact on CVD than a sole focus on individuals.

Women's Perceptions of Neighborhood Resources and Hazards Related to Diet, Physical Activity, and Smoking: Focus Group Results from Economically Distinct Neighborhoods in a Mid-Sized U.S. City

Purpose.

To investigate women's perceptions of neighborhood resources and hazards associated with poor diet, physical inactivity, and cigarette smoking.

Design.

After interviewing city officials and analyzing visual assessments, three economically distinct neighborhoods in a mid-sized city were selected.

Setting.

Salinas, California, a predominantly Latino city.

Methods.

Eight focus groups, conducted in Spanish or English in the three neighborhoods. Thematic coding of focus group transcripts identified key concepts. Women also mapped their perceived neighborhood boundaries.

Participants.

Women who had at least one child under age 18 living with them.

Results.

Women identified food stores, parks, recreation areas, and schools as key resources in their neighborhoods. They identified fast food restaurants, convenience stores, violent crime, gangs, and drug-associated issues as “hazards.” Distinctions between resources and hazards were not always clear cut. For example, parks were sometimes considered dangerous, and fast food restaurants were sometimes considered a convenient and inexpensive way to feed one's family. Women's perceptions of their neighborhood boundaries differed greatly by type of neighborhood—the perceived neighborhood area (in acres) drawn by women in the lower-income neighborhood was one-fourth the size of the area drawn by women in the higher-income neighborhood.

Conclusion.

This qualitative, exploratory study illustrates how resources and hazards in one's neighborhood cannot be viewed as having solely one dimension—each may influence health behaviors both positively and negatively.

Neighbourhood disadvantage and smoking: Examining the role of neighbourhood-level psychosocial characteristics

PURPOSE

This study aims to determine if neighbourhood psychosocial characteristics contribute to inequalities in smoking among residents from neighbourhoods of differing socioeconomic disadvantage.

METHODS

This cross-sectional study includes 11,035 residents from 200 neighbourhoods in Brisbane, Australia in 2007. Self-reported measures were obtained for smoking and neighbourhood psychosocial characteristics (perceptions of incivilities, crime and safety, and social cohesion). Neighbourhood socioeconomic disadvantage was measured using a census-derived index. Data were analysed using multilevel logistic regression random intercept models.

RESULTS

Smoking was associated with neighbourhood disadvantage; this relationship remained after adjustment for individual-level socioeconomic position. Area-level perceptions of crime and safety and social cohesion were not independently associated with smoking, and did not explain the higher prevalence of smoking in disadvantaged areas; however, perceptions of incivilities showed an independent effect.

CONCLUSIONS

Some neighbourhood psychosocial characteristics seem to contribute to the higher rates of smoking in disadvantaged areas.

Mediating role of energy-balance related behaviors in the association of neighborhood socio-economic status and residential area density with BMI: The SPOTLIGHT study

OBJECTIVES

This study aimed to examine the mediating effects of energy-balance related behaviors on the association of neighborhood socio-economic status (SES) and neighborhood residential area density (RAD) with body mass index (BMI).

METHODS

In total, 6037 adults from four neighborhood types (high SES/high RAD, high SES/low RAD, low SES/high RAD, and low SES/low RAD) in five Mid-European urban regions completed an online survey asking about their energy-balance related behaviors (physical activity [PA], sedentary behavior, and dietary behavior), determinants of these behaviors and their body weight and height. MacKinnon's product-of-coefficients test was used to assess mediating effects.

RESULTS

Transport-related PA, leisure-time PA and vegetable intake seemed to mediate the association between neighborhood type and BMI. Residents from low SES/low RAD neighborhoods reported less transport-related PA, less leisure-time PA and less vegetable intake than high SES/high RAD residents, and these behaviors (i.e. transport-related PA, leisure-time PA and vegetable intake) were related to having a higher BMI.

CONCLUSION

The association between neighborhood type and BMI can be explained, at least in part, by energy-balance related behaviors.

A discrete-time analysis of the effects of more prolonged exposure to neighborhood poverty on the risk of smoking initiation by age 25

Evidence suggests that individuals who initiate smoking at younger ages are at increased risk for future tobacco dependence and continued use as well as for numerous smoking-attributable health problems. Identifying individual, household, and to a far lesser extent, contextual factors that predict early cigarette use has garnered considerable attention over the last several decades. However, the majority of scholarship in this area has been cross-sectional or conducted over relatively short windows of observation. Few studies have investigated the effects of more prolonged exposure to smoking-related risk factors, particularly neighborhood characteristics, from childhood through early adulthood. Using the 1970-2011 waves of the Panel Study of Income Dynamics merged with census data on respondents' neighborhoods, this study estimates a series of race-specific discrete-time marginal structural logit models for the risk of smoking initiation as a function of neighborhood poverty, as well as individual and household characteristics, from ages four through 25. Neighborhood selection bias is addressed using inverse-probability-of-treatment weights. Results indicate that more prolonged exposure to high (>20%) as opposed to low (<10%) poverty neighborhoods is associated with an increased risk of smoking onset by age 25, although consistent with prior literature, this effect is only evident among white and not nonwhite youth and young adults.

Social and Environmental Factors Related to Smoking Cessation among Mothers: Findings from the Geographic Research on Wellbeing (GROW) Study

OBJECTIVES

The current study examined associations between race/ethnicity and psychosocial/environmental factors with current smoking status, and whether psychosocial/environmental factors accounted for racial differences in smoking status in a population-based sample of mothers in California.

METHODS

Cross-sectional data from 542 women with a history of smoking were used. Analyses adjusted for age, partner status, and educational attainment.

RESULTS

In models adjusted for sociodemographics, black women had significantly lower odds, and Latina immigrants had significantly higher odds of being a former smoker compared to white women. Persons smoking in the home, having a majority of friends who smoke, having perceptions of their neighborhood as being somewhat or very unsafe, and experiencing food insecurity were associated with decreased odds of being a former smoker. When these variables were entered into a single model, only being a Latina immigrant and having a majority of friends who smoke were significantly associated with smoking status.

CONCLUSIONS

Black women demonstrated a notable disparity compared with white women in smoking status, accounted for by psychosocial/environmental factors. Immigrant Latinas demonstrated notable success in ever quitting smoking. Social networks may be important barriers to smoking cessation among women.

Racial/ethnic differences in associations between neighborhood socioeconomic status, distress, and smoking among U.S. adults

Neighborhood disadvantage may increase smoking by increasing distress, while neighborhood affluence may reduce smoking by increasing positive affect. We examined whether relationships between neighborhood socioeconomic status (SES) and daily smoking operated through distress and positive affect. Simultaneous multivariate path models used pooled cross-sectional data from the 2000 and 2005 National Alcohol Surveys (15,963 respondents; weighted N = 10,753) and the 2000 Decennial Census. Multiple groups analysis assessed differences by gender and race/ethnicity. Covariates included neighborhood immigrant concentration and individual-level demographics. In the full sample, neighborhood disadvantage significantly increased smoking and neighborhood affluence significantly decreased smoking, with no indirect paths through either distress or positive affect. Unique among Hispanics, affluence resulted in decreased smoking indirectly through reduced distress. Relationships between affect and smoking also varied by race/ethnicity, with no significant differences by gender. Interventions targeting neighborhood socioeconomic status and distress may help reduce smoking, particularly for racial/ethnic minorities.

The association of individual and neighborhood social cohesion, stressors, and crime on smoking status among African-American women in southeastern US subsidized housing neighborhoods

The purpose of this study was to examine the associations between individual and neighborhood social contextual factors and smoking prevalence among African-American women in subsidized neighborhoods. We randomly sampled 663 adult women in 17 subsidized neighborhoods in two Southeastern US states. The smoking prevalence among participants was 37.6%, with an estimated neighborhood household prevalence ranging from 30 to 68%. Smokers were more likely to be older, have lower incomes, have lower BMI, and live with other smokers. Women with high social cohesion were less likely to smoke, although living in neighborhoods with higher social cohesion was not associated with smoking prevalence. Women with higher social cohesion were more likely to be older and had lived in the neighborhood longer. Women with high stress (related to violence and disorder) and who lived in neighborhoods with higher stress were more likely to smoke. Younger women were more likely to have higher stress than older women. There were no statistically significant associations with objective neighborhood crime data in any model. This is the first study to examine both individual and neighborhood social contextual correlates among African-American women in subsidized neighborhoods. This study extends findings about smoking behaviors and neighborhood social contexts in this high-risk, urban population. Future research is needed to explore age and residential stability differences and perceptions of social cohesion, neighborhood disorder, and perceived violence in subsidized housing. Further research is also warranted on African-American women, subsidized housing, smoking, social context, health disparities' effective strategies to address these individual and contextual factors to better inform future ecological-based multilevel prevention, and cessation intervention strategies.

Smoking during pregnancy was up to 70% more common in the most deprived municipalities - a multilevel analysis of all singleton births during 2005-2010 in Finland

OBJECTIVE

We investigated whether there was an association between maternal smoking habits during pregnancy and municipality level deprivation defined based on education, income and unemployment after adjustment for individual level covariates, including socioeconomic status (SES), in Finland, a Nordic welfare state.

METHODS

Data were gathered from the Medical Birth Register and comprised all singleton births (n=337,876) during 2005-2010. To account for any correlation of women clustered within a municipality, we fitted generalized estimating equation (GEE) models.

RESULTS

In total, 15.3% of the women with singleton pregnancies smoked during pregnancy. After adjustment for individual level confounders, smoking during pregnancy was 5.4-fold higher among women with the lowest as compared with highest individual SES. Controlling for individual SES, age and year of birth, women living in municipalities defined as intermediately and highly deprived based on education were 53.7% (adjusted odds ratio [aOR] 1.537, 95% confidence interval [CI] 1.493-1.583) and 71.5% (aOR 1.715, 95% CI 1.647-1.785), respectively, more likely to smoke during pregnancy than women in the least deprived municipalities.

CONCLUSIONS

Individual SES is the strongest correlate of smoking during pregnancy but conditional on individual variables; lower municipality aggregate education is associated with up to 70% higher smoking prevalence.

A multilevel analysis of gender, Latino immigrant enclaves, and tobacco use behavior

Research suggests that immigrant enclaves positively influence health behaviors such as tobacco use through supportive social networks and informal social control mechanisms that promote healthy behavioral norms. Yet, the influence of social cohesion and control on tobacco use may depend on smoking-related norms, which can vary by gender. This study examines the influence of neighborhood Latino immigrant enclave status on smoking and cessation among Hispanic men and women. Data from the Los Angeles Family and Neighborhood Survey was combined with census data to assess the relationship between immigrant enclaves, gender, and smoking using multilevel regression. The effect of the Hispanic enclave environment on smoking differed by gender. Living in an enclave had a harmful effect on tobacco use among Hispanic men, marginally increasing the likelihood of smoking and significantly reducing cessation. This effect was independent of neighborhood socioeconomic status, nativity, and other individual demographics. Neighborhood immigrant concentration was not associated with smoking or cessation for Hispanic women. Research, interventions, and policies aimed at reducing smoking among Hispanics may need to be gender responsive to ensure effectiveness as well as health and gender equity.

Smoking and major depressive disorder in Chinese women

Objective

To investigate the risk factors that contribute to smoking in female patients with major depressive disorder (MDD) and the clinical features in depressed smokers.

Methods

We examined the smoking status and clinical features in 6120 Han Chinese women with MDD (DSM-IV) between 30 and 60 years of age across China. Logistic regression was used to determine the association between clinical features of MDD and smoking status and between risk factors for MDD and smoking status.

Results

Among the recurrent MDD patients there were 216(3.6%) current smokers, 117 (2.0%) former smokers and 333(5.6%) lifetime smokers. Lifetime smokers had a slightly more severe illness, characterized by more episodes, longer duration, more comorbid illness (panic and phobias), with more DSM-IV A criteria and reported more symptoms of fatigue and suicidal ideation or attempts than never smokers. Some known risk factors for MDD were also differentially represented among smokers compared to non-smokers. Smokers reported more stressful life events, were more likely to report childhood sexual abuse, had higher levels of neuroticism and an increased rate of familial MDD. Only neuroticism was significantly related to nicotine dependence.

Conclusions

Although depressed women smokers experience more severe illness, smoking rates remain low in MDD patients. Family history of MDD and environmental factors contribute to lifetime smoking in Chinese women, consistent with the hypothesis that the association of smoking and depression may be caused by common underlying factors.

Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: findings from the ITC Mexico Survey

BACKGROUND

In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

OBJECTIVE

To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

METHODS

Data were analysed from adult smokers and recent ex-smokers who participated in waves 4-6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

FINDINGS

Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

CONCLUSIONS

Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.

Long-term effects of adolescent smoking on depression and socioeconomic status in adulthood in an urban African American cohort

Despite known adverse causal effects of cigarette smoking on mental health, findings for the effects of adolescent cigarette smoking on later depression and socioeconomic status remain inconclusive. Previous studies have had shorter follow-up periods and did not have a representative portion of the African American population. Using an analytical method that matches adolescent smokers with nonsmokers on childhood and background variables, this study aims to provide evidence on the effects of adolescent regular smoking on adult depression and socioeconomic status. Our longitudinal study is from the Woodlawn Study that followed 1,242 African Americans in Chicago from 1966-1967 (at age 6-7) through 2002-2003 (at age 42-43). We used a propensity score matching method to find a regular and a non-regular adolescent smoking group with similar childhood socioeconomic and family background and first grade academic and behavioral performance. We compared the matched samples to assess the longitudinal effects of adolescent smoking on adult outcomes. Comparing the matched 199 adolescent regular smokers and 199 non-regular smokers, we found statistical support for the effects of adolescent cigarette smoking on later educational attainment (OR, 2.13; 95 % CI, 1.34, 3.39) and long-term unemployment (OR, 1.74; 95 % CI, 1.11, 2.75), but did not find support for the effects on adulthood major depressive disorders. With a community population of urban African Americans followed for 40 years, our study contributes to the understanding of the relationships between adolescent smoking and later educational attainment and employment.

Neighborhood socioeconomic status and substance use by U.S. adults

BACKGROUND

This study examined relationships of extremes in neighborhood socioeconomic status with use of tobacco, alcohol, marijuana and other drugs. Hypotheses were (1) residence in disadvantaged neighborhoods would be positively associated with stress-related and higher-risk substance use patterns (e.g., drug use), and (2) residence in affluent neighborhoods would be positively associated with "healthy" substance use (e.g., drinking within recommended guidelines) and negatively associated with substance use patterns incompatible with a culture of health. Age was examined as a potential moderator.

METHODS

Data were from nationally-representative samples of U.S. adults (N=14,531) from the 2000 and 2005 National Alcohol Surveys linked with indicators of neighborhood SES from the 2000 U.S. Decennial Census. Analyses included gender-stratified multivariate logistic regression using weights to adjust for sampling and non-response.

RESULTS

As hypothesized, compared to middle-class neighborhoods, residence in disadvantaged neighborhoods was associated with higher odds of both men's and women's tobacco use and with women's other drug use. Residence in affluent neighborhoods was associated with lower odds of men's tobacco use and women's marijuana use. The association of neighborhood SES with men's tobacco use was modified by age, with the highest odds of daily tobacco use evident for all men in disadvantaged neighborhoods, as well as for younger men in middle-class neighborhoods. There were no significant associations of either alcohol outcome with neighborhood SES.

CONCLUSIONS

Increased risk of substance use for younger residents in both disadvantaged and middle-class neighborhoods and for older residents in disadvantaged neighborhoods suggest a need for targeted prevention interventions.

Environmental interventions to reduce fear of crime: systematic review of effectiveness

BACKGROUND

Fear of crime is associated with negative health and wellbeing outcomes, and may mediate some impacts of the built environment on public health. A range of environmental interventions have been hypothesized to reduce the fear of crime.

METHODS

This review aimed to synthesize the literature on the effectiveness of interventions in the built environment to reduce the fear of crime. Systematic review methodology, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, was used. Studies of environmental interventions which reported a fear of crime outcome and used any prospective evaluation design (randomized controlled trial (RCT), trial or uncontrolled before-and-after study) were included. Eighteen databases were searched. The Hamilton tool was used to assess quality. A narrative synthesis of findings was undertaken.

RESULTS

A total of 47 studies were included, 22 controlled and 25 uncontrolled, with total sample sizes ranging from n = 52 to approximately n = 23,000. Thirty-six studies were conducted in the UK, ten studies in the USA and one study in the Netherlands. The quality of the evidence overall is low. There are some indications that home security improvements and non-crime-related environmental improvements may be effective for some fear of crime outcomes. There is little evidence that the following reduce fear of crime: street lighting improvements, closed-circuit television (CCTV), multi-component environmental crime prevention programs or regeneration programs.

CONCLUSIONS

There is some evidence for the effectiveness of specific environmental interventions in reducing some indicators of fear of crime, but more attention to the context and possible confounders is needed in future evaluations of complex social interventions such as these.

Smoking initiation, continuation and prevalence in deprived urban areas compared to non-deprived urban areas in The Netherlands

Previous studies have shown that smoking prevalence is higher in deprived areas than in affluent areas. We aimed to determine whether smoking initiation or continuation contributes most to inequalities in current smoking, and in which population subgroups these area differences were largest. Therefore, we assessed the relationship between area deprivation and current smoking, initiation and continuation in urban areas, in subgroups defined by gender, generation and educational level. Cross-sectional data of 20,603 Dutch adults (18 years and over) living in 963 urban areas in The Netherlands were obtained from the annual national health survey (2003-2009). Three interrelated smoking outcomes were used: current smoking (smokers/total population), initiation (ever-smokers/total population) and continuation (smokers/ever-smokers). Area deprivation was dichotomised; deprived urban areas (as defined by the Dutch government) and non-deprived urban areas (reference group) were distinguished. Multilevel logistic regression models controlled for individual characteristics (including education and income) and tested for interaction with gender, generation and education. After controlling for individual characteristics, odds for smoking were not significantly higher in deprived areas (current smoking: OR = 1.04 [0.92-1.18], initiation: OR = 1.05 [0.93-1.18], continuation: OR = 1.03 [0.88-1.19]). For smoking initiation, significant differences between deprived areas and other areas remained in younger generations (OR = 1.19 [1.02-1.38]) and higher educated (OR = 1.23 [1.04-1.45]) respondents. For continuation and current smoking, after controlling for individual characteristics, no associations were found in any subgroups. In conclusion, area deprivation appears to be independently related to smoking initiation in, respectively, higher educated and younger generations. These results suggest that initiatives to reduce area-level inequalities in smoking should focus on preventing smoking initiation in deprived areas.

Community-level socioeconomic status and parental smoking in Japan

Community-level social environment has been considered to be associated with smoking behavior. However, no study has examined the association between community-level environmental factors and parental smoking behavior in families with young children. The aim of the present study was to examine the association between community-level socioeconomic status (SES) and parental smoking behavior. We used data from a cross-sectional study conducted from 2005 to 2006. We randomly selected 44 Japanese municipalities, 39 of which municipalities agreed to participate in this survey. The study subjects were participants in health check-ups for three-year-old children. Smoking status and individual demographic characteristics were obtained using self-administered questionnaires. Community-level variables were obtained from national census data for 2005. The prevalence of employment in tertiary industries and of unemployment was used to measure community-level SES. Multilevel Poisson regression models were used to calculate prevalence ratios (PRs) for smoking. Of 4143 subjects, a total of 3301 parents in 39 municipalities participated in our survey. Among the 2975 participants (71.8%) included in our analysis, 59.0% were smokers. There was no association between the job of the head of the household considered as an indicator of individual-level SES and smoking. By contrast, when we examined the relationship between prevalence of employment in tertiary industries as community-level SES and smoking, parents living in low middle SES municipalities had a significantly higher prevalence ratio for smoking, compared to parents living in the highest SES municipalities. This result suggested that those with lower community-level SES tended to have a higher prevalence of parental smoking regardless of individual-level SES.

Menthol smoking in relation to time to first cigarette and cotinine: results from a community-based study

Smokers who have their first cigarette shortly after waking, an indicator of nicotine dependence, have substantially higher cotinine levels. There is controversy regarding the role of menthol in nicotine dependence. We hypothesized that menthol smokers have a shorter time to first cigarette (TTFC), and tested whether any statistical association actually reflects increased dependence by measuring nicotine uptake (e.g. cotinine) in the same group of smokers. A cross-sectional community-based study was conducted that included 495 black and white daily cigarette smokers. Results showed a trend between menthol smoking and a shorter TTFC (P < 0.04 in blacks). Menthol was not an independent predictor of cotinine or an effect modifier with TTFC on cotinine levels in blacks and whites. These results show that while menthol in tobacco is associated with an indicator of nicotine dependence in blacks, menthol was not associated with biological uptake of nicotine in black and white smokers.

Individual and community predictors of maternal smoking in the city of Baltimore: what can be learned from a predominantly minority case controlled study?

This case control study of 1,000 birth certificates examined what individual and community factors predicted maternal smoking in Baltimore, Maryland. Conditional multinomial logistic regression results indicated women who were White were more likely to start smoking at a young age, but as they got older, they were less likely to smoke. Minority women were more likely to start smoking at a later age. Also, White women were more likely to smoke as the rate of poverty increased, while for minority women, smoking was unrelated to whether they lived in higher or lower poverty areas. Medical assistance status, community education level, and crime rate were not found to be related to smoking status.

Social norms, collective efficacy, and smoking cessation in urban neighborhoods

OBJECTIVES

We examined the separate and combined relations of neighborhood-level social norms and collective efficacy with individuals' cigarette smoking cessation.

METHODS

We modeled the hazard of quitting over a 5-year period among 863 smokers who participated in the 2005 New York Social Environment Study.

RESULTS

In adjusted Cox proportional hazard models, prohibitive neighborhood smoking norms were significantly associated with higher rates of smoking cessation (second quartile hazard ratio [HR] = 1.17; 95% confidence interval [CI] = 0.59, 2.32; third quartile HR = 2.37; 95% CI = 1.17, 4.78; fourth quartile HR = 1.80; 95% CI = 0.85, 3.81). We did not find a significant association between neighborhood collective efficacy and cessation or significant evidence of a joint relation of collective efficacy and smoking norms with cessation.

CONCLUSIONS

Neighborhood social norms may be more relevant than is collective efficacy to smoking cessation. The normative environment may shape health behavior and should be considered as part of public health intervention efforts.

Neighbourhood crime and smoking: the role of objective and perceived crime measures

Background

Smoking is a major public health problem worldwide. Research has shown that neighbourhood of residence is independently associated with the likelihood of individuals' smoking. However, a fine comprehension of which neighbourhood characteristics are involved and how remains limited. In this study we examine the relative contribution of objective (police-recorded) and subjective (resident-perceived) measures of neighbourhood crime on residents' smoking behaviours.

Methods

Data from 2,418 men and women participating in the 2007/8 sweep of the West of Scotland Twenty-07 Study were analyzed. Smoking status and perceived crime were collected through face-to-face interviews with participants. Police-recorded crime rates were obtained from the Scottish Neighbourhood Statistics website at the datazone scale. Adjusted odds ratios and 95% confidence intervals were estimated for the likelihood of current smoking using logistic regression models. Adjusted mean daily amount smoked and F statistics were calculated using general linear models. Analyses were conducted for all respondents and stratified by sex and age cohort.

Results

Compared to individuals living in low crime areas, those residing in an area characterized by high police-recorded crime rates or those perceiving high crime in their neighbourhood were more likely to be current smokers, after controlling for individual characteristics. The association with smoking was somewhat stronger for police-recorded crime than for perceived crime. Associations were only slightly attenuated when adjusting for either the objective or subjective crime measures, suggesting that these indicators may exert an independent influence on the risk of smoking. Stronger effects were observed for women compared to men. Police-recorded crime rates were more strongly related to smoking status among older respondents than among the younger cohort, whereas the strongest effect for perceived crime was observed among younger participants.

Conclusions

Our findings highlight the relevance of paying attention to both objective and perceived neighbourhood crime measures when aiming to prevent smoking.

Individual and neighborhood-level socioeconomic characteristics in relation to smoking prevalence among black and white adults in the Southeastern United States: a cross-sectional study

Background

Low individual-level socioeconomic status (SES) is associated with higher prevalence of cigarette smoking. Recent work has examined whether neighborhood-level SES may affect smoking behavior independently from individual-level measures. However, few comparisons of neighborhood-level effects on smoking by race and gender are available.

Methods

Cross-sectional data from adults age 40-79 enrolled in the Southern Community Cohort Study from 2002-2009 (19, 561 black males; 27, 412 black females; 6, 231 white males; 11, 756 white females) were used in Robust Poisson regression models to estimate prevalence ratios (PRs) and 95% confidence intervals (CI) for current smoking in relation to individual-level SES characteristics obtained via interview and neighborhood-level SES characteristics represented by demographic measures from US Census block groups matched to participant home addresses.

Results

Several neighborhood-level SES characteristics were modestly associated with increased smoking after adjustment for individual-level factors including lower percentage of adults with a college education and lower percentage of owner-occupied households among blacks but not whites; lower percentage of households with interest, dividends, or net rental income among white males; and lower percentage of employed adults among black females.

Conclusions

Lower neighborhood-level SES is associated with increased smoking suggesting that cessation programs may benefit from targeting higher-risk neighborhoods as well as individuals.

Adolescent smoking risk increases with wider income gaps between rich and poor

Data from a state-wide survey of California middle and high school students (N=20,203) were used to assess whether county income inequality and poverty rates were associated with adolescent smoking. Greater county income inequality, but not poverty rates, was associated with higher established smoking risk (p=0.0019). The association was stronger in males than females, whites than other ethnic groups, and urban than rural settings. Neither county income inequality nor poverty rates were associated with experimental smoking. The findings suggest that it may be important to consider and address economic inequality in the prevention and control of adolescent tobacco use.

Prevalence and Correlates of Problem Behaviors Among Adolescents in Hong Kong

The aims of this study were to examine the frequency and correlates of problem behaviors among Hong Kong adolescents. It is a cross-sectional survey targeting secondary forms 1 to 3 (equivalent to grades 7-9 in the United States) students (N = 1029). A self-administered questionnaire was used as the measurement tool. The study found that there are intercorrelations of problem behaviors in adolescence, such as tobacco use, alcohol use, drug abuse, and having connections with triad society. Given the intercorrelations among problem behaviors, identification of a single type of problem behavior in adolescents can help discover the likelihood of the occurrence of other problem behaviors. It can facilitate identification and intervention at an early stage. The results provide some insights for the concerned authorities to develop a syndrome approach addressing problem behaviors.

Are perceived neighbourhood problems associated with the likelihood of smoking?

OBJECTIVE

To explore associations between residents' perceptions of the local residential environment and the likelihood of their smoking.

DESIGN

Using data (n = 2615) from the West of Scotland Twenty-07 Study, separately by gender, cross-sectional associations between respondents' perceptions of neighbourhood (perceived absence of goods, incivilities and physical environmental problems) and the likelihood of being a current smoker and the amount smoked were examined.

RESULTS

Perceived neighbourhood problems are associated with the likelihood of smoking but mainly among those with the most negative view of the local neighbourhood. Perceptions of the provision of neighbourhood amenities seems to be more strongly associated with women's than men's smoking status, whereas the perceived quality of the local neighbourhood appears to be a better predictor of men's smoking.

CONCLUSIONS

Efforts to reduce smoking levels among more deprived groups may need to pay more attention to the role of local environmental conditions in influencing smoking behaviour.

Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure

This article explores the psychosocial and social-structural vulnerability in relation to women's tobacco use, smoke exposure and responses to policy, and examines these issues in the context of women's lives and roles, describing forward looking strategies that could improve research and equity in outcomes for women. Various literatures on smoking among women and girls, and how women and sub-populations of women respond to tobacco control policies are reviewed. Specific sub-populations exhibiting more tobacco use and exposure are described, such as young pregnant and mothering women and low-income women. Emerging evidence also reveals links between smoking and experiences such as childhood sexual abuse, interpersonal violence, post-traumatic stress disorder, mental health issues and alcohol and drug dependence. Varied sub-populations of women respond in different ways to price and taxation, sales restrictions and location restrictions. However, tobacco control policies have, to date, been fashioned as broad instruments, not taking into account social context, trauma backgrounds, gendered roles such as mothering, unequal power relations affecting women in relationships and workplaces, and differences in access to resources and social support. When these issues are considered, the implications for tobacco policy development include: widening the policy purview, accounting for uneven and differential responses to policies, committing to an ethical framework, extending sex, gender and diversity based analyses, and improving research methods and approaches.

The influence of housing tenure and marital status on smoking in South Korea

OBJECTIVE

This study aimed to identify the most influential socioeconomic indicator of smoking in South Korea.

METHODS

This study analyzed a nationally representative sample (6141 men and 7133 women aged 20-65) from the 2001 and 2005 Korea National Health and Nutrition Surveys. Weighted estimates were computed, adjusting for a complex survey design using "surveyfreq" and "surveylogistic" procedures of SAS 9.1 software.

RESULTS

The adjusted OR for smoking in renters compared to homeowners was 1.50 (95% CI: 1.32-1.71) in men and 3.21 (95% CI: 2.41-4.27) in women, and larger in the older than younger groups. For non-married versus married individuals, the OR was 1.37 (95% CI: 1.19-1.59) in men and 3.25 (95% CI: 2.48-4.25) in women; the OR in non-married renters compared married homeowners was 1.79 (95% CI: 1.45-2.22) in men and 10.63 (95% CI: 7.31-15.45) in women.

CONCLUSION

Housing tenure was a strong predictor of smoking in South Korea and its significance was very pronounced in non-married individuals. Housing policies to encourage homeownership could be effective in reducing smoking in countries such as China, India, and Vietnam where house ownership is regarded as the ultimate financial safeguard, there are numerous, and traditional attitudes toward marriage are undergoing transition.

Factors affecting smoking tendency and smoking intensity

Purpose

The purpose of this paper is to measure the relative effect of relevant explanatory variable on smoking tendency and smoking intensity.

Design/methodology/approach

Using survey data collected by the Israeli Bureau of Statistics in 2003‐2004, a probit procedure is estimated for analyzing factors that affect the probability of being a smoker. Using ordinary least square methods, the factors that affect smoking intensity are also estimated.

Findings

The findings show that the probability of being a smoker, as well as having greater intensity of smoking, is larger for males, non‐Jews, and those who are un‐married and younger. When estimating different equations for males and females, the results for males are in the same direction as the results for all sample observations, but for females it is found that being Jewish significantly increases smoking probability and females born in America or Europe smoke more intensively.

Research limitations/implications

Our findings enable the focusing of the relevant authorities' attention on the population that is at a higher risk of smoking.

Practical implications

Concurrent with the necessary legislation, a strategy has to be developed that can appropriately target the different educational, ethnic, age and gender groups, and effectively communicate the correct health message that will properly impact on long‐term behavior.

Originality/value

The findings contribute to existing knowledge in two main aspects: the first is in measuring the relative effect of each significant explanatory variable on smoking tendency and smoking intensity. The second is in using a unique data set that includes many agents' characteristics and examining the significance of the various characteristics on smoking tendency and smoking intensity.

Association between neighborhood context and smoking prevalence among Asian Americans

OBJECTIVES

To study neighborhood-level determinants of smoking among Asian Americans, we examined 3 neighborhood factors (ethnic enclave, socioeconomics, and perceived social cohesion) and smoking prevalence in a population-based sample.

METHODS

We linked data from the 2003 California Health Interview Survey to tract-level data from the 2000 Census. We used multivariate logistic regression models to estimate the associations between smoking and neighborhood-level factors, independent of individual factors.

RESULTS

Twenty-two percent of 1693 Asian men and 6% of 2174 Asian women reported current smoking. Women living in an Asian enclave were less likely to smoke (adjusted odds ratio [AOR] = 0.27; 95% confidence interval [CI] = 0.08, 0.88). Among men, higher levels of perceived neighborhood social cohesion were associated with lower odds of smoking (AOR = 0.74; 95% CI = 0.61, 0.91).

CONCLUSIONS

The association between contextual factors and smoking differed for men and women. For women, living in an Asian enclave may represent cultural behavioral norms. For men, neighborhood trust and cohesiveness may buffer stress. Smoking prevention and cessation interventions among Asian Americans may be more effective if they address contextual factors.

Small-area estimation and prioritizing communities for tobacco control efforts in Massachusetts

OBJECTIVES

We developed a method to evaluate geographic and temporal variations in community-level risk factors and prevalence estimates, and used that method to identify communities in Massachusetts that should be considered high priority communities for smoking interventions.

METHODS

We integrated individual-level data from the Behavioral Risk Factor Surveillance System from 1999 to 2005 with community-level data in Massachusetts. We used small-area estimation models to assess the associations of adults' smoking status with both individual- and community-level characteristics and to estimate community-specific smoking prevalence in 398 communities. We classified communities into 8 groups according to their prevalence estimates, the precision of the estimates, and temporal trends.

RESULTS

Community-level prevalence of current cigarette smoking among adults ranged from 5% to 36% in 2005 and declined in all but 16 (4%) communities between 1999 and 2005. However, less than 15% of the communities met the national prevalence goal of 12% or less. High smoking prevalence remained in communities with lower income, higher percentage of blue-collar workers, and higher density of tobacco outlets.

CONCLUSIONS

Prioritizing communities for intervention can be accomplished through the use of small-area estimation models. In Massachusetts, socioeconomically disadvantaged communities have high smoking prevalence rates and should be of high priority to those working to control tobacco use.

Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior

BACKGROUND

Although neighborhoods with more collective efficacy have better health in general, recent work suggests that social norms and collective efficacy may in combination influence health behaviors such as smoking.

METHODS

Using data from the New York Social Environment Study (conducted in 2005; n=4000), we examined the separate and combined associations of neighborhood collective efficacy and anti-smoking norms with individual smoking. The outcome was current smoking, assessed using the World Mental Health Comprehensive International Diagnostic Interview (WMH-CIDI) tobacco module. Exposures of interest were neighborhood collective efficacy, measured as the average neighborhood response on a well-established scale, and neighborhood anti-smoking norms, measured as the proportion of residents who believed regular smoking was unacceptable. All analyses adjusted for demographic and socioeconomic characteristics, as well as history of smoking prior to residence in the current neighborhood, individual perception of smoking level in the neighborhood, individual perception of collective efficacy, and individual smoking norms.

RESULTS

In separate generalized estimating equation logistic regression models, neighborhood collective efficacy was not associated with smoking (OR 1.06, 95% CI 0.84-1.34) but permissive neighborhood smoking norms were associated with more smoking (OR 1.34, 95% CI 1.03-1.74), particularly among residents with no prior history of smoking (OR 2.88, 95% CI 1.92-4.30). When considered in combination, where smoking norms were permissive, higher collective efficacy was associated with more smoking; in contrast, where norms were strongly anti-smoking, higher collective efficacy was associated with less smoking.

CONCLUSIONS

Features of the neighborhood social environment may need to be considered in combinations to understand their role in shaping health and health behavior.

Smoking in context - a multilevel approach to smoking among females in Helsinki

Background

Smoking is associated with disadvantage. As people with lower social status reside in less privileged areas, the extent of contextual influences for smoking remains unclear. The aims were to examine the spatial patterning of daily smoking within the city of Helsinki, to analyse whether contextual variation can be observed and which spatial factors associate with current daily smoking in the employed female population.

Methods

Data from a cross-sectional questionnaire were collected for municipal employees of Helsinki (aged 40–60 years). The response rate was 69%. As almost 4/5 of the employees are females, the analyses were restricted to women (n = 5028). Measures included smoking status, individual level socio-demographic characteristics (age, occupational social class, education, family type) and statistical data describing areas in terms of social structure (unemployment rate, proportion of manual workers) and social cohesion (proportions of single parents and single households). Logistic multilevel analysis was used to analyse data.

Results

After adjusting for the individual-level composition, smoking was significantly more prevalent according to all social structural and social cohesion indicators apart from the proportion of manual workers. For example, high unemployment in the area of domicile increased the risk of smoking by almost a half. The largest observed area difference in smoking – 8 percentage points – was found according to the proportion of single households.

Conclusion

The large variation in smoking rates between areas appears mainly to result from variation in the characteristics of residents within areas. Yet, living in an area with a high level of unemployment appears to be an additional risk for smoking that cannot be fully accounted for by individual level characteristics even in a cohort of female municipal employees.

Neighborhood residence and cigarette smoking among urban youths: the protective role of prosocial activities

OBJECTIVES

We examined the association between neighborhood characteristics and cigarette use among adolescents and explored the protective effects of participation in prosocial activities to better understand strengths in adolescents' lives and help identify protective factors for the prevention of adolescent smoking.

METHODS

We interviewed ninth graders who had grade point averages of 3.0 or lower and who were not developmentally disabled. Participants' addresses were geocoded so that interview data could be linked to 1990 US census data on neighborhood characteristics.

RESULTS

Neighborhood disadvantage and the percentage of Black residents in a neighborhood had different effects on cigarette smoking among Black and White adolescents. Living in a neighborhood with a high percentage of Black residents had favorable effects for Blacks but not for Whites. For both groups, a low percentage of Black residents was a risk factor for cigarette use, and risk effects were higher in the more disadvantaged neighborhoods. Involvement in prosocial activities moderated neighborhood risks.

CONCLUSIONS

Neighborhood effects on adolescent cigarette use were contingent upon both contextual and individual characteristics. Participation in prosocial activities had a protective effect among adolescents in high-risk neighborhoods. Engaging adolescents in such activities may help offset the adverse effects of living in a disadvantaged neighborhood.

Education inequality and use of cigarettes, alcohol, and marijuana

Education inequality at the neighborhood-level may influence population health and health behavior. We assessed the relations between education inequality and substance use in 59 New York City (NYC) neighborhoods. We used Gini coefficients of education to describe neighborhood education inequality and data from a random-digit-dial phone survey of adult residents of NYC to assess use of substances. Among 1355 respondents (female=56.2%; white=35.7%; mean age=40.4), 23.9% (95% confidence interval [CI]=20.3-27.5) reported smoking, 39.4% (95% CI=35.3-43.4) drinking, and 5.4% (95% CI=3.6-7.3) using marijuana in the previous 30 days. In multilevel models controlling for neighborhood education, neighborhood income inequality, and individual covariates, living in a neighborhood with high education inequality was associated with a greater prevalence of drinking (p=0.02) and of smoking marijuana (p=0.004) but among current drinkers it was associated (p=0.03) with having fewer drinks. The odds of alcohol use (OR=1.70) and marijuana use (OR=3.49) were greater in neighborhoods in the 75th percentile of education Gini compared to neighborhoods in the 25th percentile of education Gini. Statisical interactions suggest that there may be a stronger relation between education inequality and marijuana use in neighborhoods with low mean education than in neighborhoods with higher mean levels of education. These findings, taken together, suggest a complex relation between education inequality and substance use; likelihood of the use of alcohol and marijuana was higher in areas with higher education inequality suggesting potential roles for substance use norms and availability, whereas quantity used among drinkers was higher in areas with low education inequality, suggesting potential roles for both disadvantage and norms.

Disparities in smoking: data from the Nashville REACH 2010 project

The Nashville REACH 2010 project is funded by the Centers for Disease Control and Prevention to reduce health disparities in diabetes and heart disease among African Americans in Nashville, Tenn. While Tennessee has the third highest smoking rate (26.1%) in the United States, there are few appropriate local data useful for planning and evaluating local antismoking interventions. Data gathered for Nashville REACH 2010 from 4 large random telephone surveys were pooled to produce a database (n = 15,076) to define the extent of the local smoking disparity and the subgroups with the highest and lowest prevalence of smoking. African American women were least likely to smoke (21.3%) followed by white women (24.9%), and then African American and white men (27.3% and 27.9%, respectively). Among African American subgroups, smoking was lowest in students (10.8%) and retirees (17.1%) and highest in unemployed men (45.9%). In a logistic regression, smoking was highest among single men, the lowest educational level, the unemployed, the lowest income groups, and those between 40 and 50 years of age.

Neighborhood income and income distribution and the use of cigarettes, alcohol, and marijuana

Evidence about the relationship between contextual variables and substance use is conflicting. Relationships between neighborhood income and income distribution and the prevalence and frequency of substance use in 59 New York City (NYC) neighborhoods were assessed while accounting for individual income and other socio-demographic variables. Measures of current substance use (in the 30 days prior to the survey) were obtained from a random-digit-dial phone survey of adult residents of NYC and data from the 2000 U.S. Census to calculate median neighborhood income and income distribution (assessed using the Gini coefficient). Among 1355 respondents analyzed (female=56.2%, mean age=40.4), 23.9% reported cigarette, 40.0% alcohol, and 5.4% marijuana use in the previous 30 days. In ecologic assessment, neighborhoods with both the highest income and the highest income maldistribution had the highest prevalence of drinking alcohol (69.0%) and of smoking marijuana (10.5%) but not of cigarette use; there was no clear ecologic association between neighborhood income, income distribution, and cigarette use. In multilevel multivariable models adjusting for individual income, age, race, sex, and education, high neighborhood median income and maldistributed neighborhood income were both significantly associated with a greater likelihood of alcohol and marijuana use but not of cigarette use. Both high neighborhood income and maldistributed income also were associated with greater frequency of alcohol use among current alcohol drinkers. These observations suggest that neighborhood income and income distribution may play more important roles in determining population use of alcohol and marijuana than individual income, and that determinants of substance use may vary by potential for drug dependence. Further research should investigate specific pathways that may explain the relationship between neighborhood characteristics and use of different substances.

Average household income, crime, and smoking behaviour in a local area: The Finnish 10-Town study

Social environments, like neighbourhoods, are increasingly recognised as determinants of health. While several studies have reported an association of low neighbourhood socio-economic status with morbidity, mortality and health risk behaviour, little is known of the health effects of neighbourhood crime rates. Using the ongoing 10-Town study in Finland, we examined the relations of average household income and crime rate measured at the local area level, with smoking status and intensity by linking census data of local area characteristics from 181 postal zip codes to survey responses to smoking behaviour in a cohort of 23,008 municipal employees. Gender-stratified multilevel analyses adjusted for age and individual occupational status revealed an association between low local area income rate and current smoking. High local area crime rate was also associated with current smoking. Both local area characteristics were strongly associated with smoking intensity. Among ever-smokers, being an ex-smoker was less likely among residents in areas with low average household income and a high crime rate. In the fully adjusted model, the association between local area income and smoking behaviour among women was substantially explained by the area-level crime rate. This study extends our knowledge of potential pathways through which social environmental factors may affect health.

Inequities in CHD incidence and case fatality by neighborhood deprivation

BACKGROUND

Research has not firmly established whether living in a deprived neighborhood predicts the incidence and case fatality of coronary heart disease (CHD), and whether effects vary across sociodemographic groups.

METHODS

Prospective follow-up study of all Swedish women and men, aged 35 to 74 (1.9 million women, 1.8 million men). Women and men, without a history of CHD, were assessed on December 31, 1995, and followed from January 1, 1996 through December 31, 2000, for first fatal or nonfatal CHD event (130,024 cases); data were analyzed in 2006. Neighborhood-level deprivation (index of education, income, unemployment, welfare assistance) was categorized as low, moderate, and high deprivation.

RESULTS

Age-standardized CHD incidence was 1.9 times higher for women and 1.5 times higher for men in high- versus low-deprivation neighborhoods; 1-year case fatality from CHD was 1.6 times higher for women and 1.7 times higher for men in high versus low deprivation neighborhoods. The higher incidence in more deprived neighborhoods was observed across all individual-level sociodemographic groups (age, marital status, family income, education, immigration status, mobility, and urban/rural status). In multilevel logistic regression models, neighborhood deprivation remained significantly associated with both CHD incidence and case fatality for women and men after adjusting for the seven sociodemographic factors (p values <0.01). Effects were slightly stronger for women than men in an ancillary analysis that tested for gender differences.

CONCLUSIONS

The clustering of CHD and subsequent mortality among adults in deprived neighborhoods raises important clinical and public health concerns, and calls for a reframing of health problems to include neighborhood social environments, as they may affect health.