The European Journal of Public Health Advance Access originally published online on March 8, 2005
The European Journal of Public Health 2005 15(3):262-269; doi:10.1093/eurpub/cki115
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Smoking |
Socioeconomic status and smoking
Analysing inequalities with multiple indicators
Mikko Laaksonen1, Ossi Rahkonen2, Sakari Karvonen3 and Eero Lahelma1
1 Department of Public Health, University of Helsinki, Helsinki, Finland
2 Department of Social Policy, University of Helsinki, Helsinki, Finland
3 STAKES (National Research and Development Centre for Welfare and Health), Helsinki, Finland
Correspondence: Mikko Laaksonen, PhD, Department of Public Health, PO Box 41, FIN-00014 University of Helsinki, Helsinki, Finland, tel. +358 9 191 27569, fax +358 9 191 27570, Email: mikko.t.laaksonen{at}helsinki.fi
Received July 2, 2003, accepted January 20, 2004
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Abstract |
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Background and aims: Socioeconomic differences in smoking have been well established. While previous studies have mostly relied on one socioeconomic indicator at a time, this study examined socioeconomic differences in smoking by using several indicators that reflect different dimensions of socioeconomic position. Data and methods: Data derive from Helsinki Health Study baseline surveys conducted among the employees of the City of Helsinki in 2000 and 2001. The data include 6243 respondents aged 40–60 years (response rate 68%). Six socioeconomic indicators were used: education, occupational status, household income per consumption unit, housing tenure, economic difficulties and economic satisfaction. Their associations with current smoking were examined by fitting sequential logistic regression models. Results: All socioeconomic indicators were strongly associated with smoking among both men and women. When the indicators were examined simultaneously their associations with smoking attenuated, especially when education and occupational status were considered together, and when income and housing tenure were introduced into the models already containing education and occupational status. After mutual adjustment for all socioeconomic indicators, housing tenure and economic satisfaction remained associated with smoking in men. In women, all indicators except income and economic difficulties were inversely associated with smoking after adjustments. Conclusions: Smoking was associated with structural, material as well as perceived dimensions of socioeconomic disadvantage. Attempts to reduce smoking among the socioeconomically disadvantaged need to target several dimensions of socioeconomic position.
Keywords: education, income, occupational status, smoking, socioeconomic differences
Cigarette smoking is a leading cause of morbidity and mortality in industrial societies. Over recent decades, the overall prevalence of smoking has decreased among men in many countries, whereas among women smoking has remained at the same level or even increased.1 However, these changes have not happened equally across all population groups. In most industrial societies smoking has increasingly been concentrated among the socioeconomically disadvantaged. This is particularly true for northern European men, but also women and southern Europeans seem to be moving towards a similar pattern.2,3
Various explanations for the socioeconomic differences in smoking have been put forward. These include lack of knowledge, scarce material resources and psychosocial stress due to an unfavourable social position and poor material conditions.4,5 These explanations may relate differently to the various indicators that have been used to measure socioeconomic position. Education, occupational status and income as well as other measures of material living conditions have all been found to be inversely associated with smoking.3,4,6 While each of these indicators is likely to reflect one's position in socioeconomic hierarchy, they all also have specific characteristics that may be suggestive about the different explanations for the association between socioeconomic position and smoking.
Educational level and occupational status link people to social structure. Occupational status is the conventional measure of one's position in the socioeconomic hierarchy, and it is more closely connected with working conditions than other socioeconomic indicators.7 Occupational status is closely related to one's educational level. In health behaviour research, educational level may be an especially important socioeconomic indicator, as it may reflect knowledge and skills that are important for making health behaviour choices better than the other indicators, for example those concerning smoking.8,9
Education and occupation also influence people's access to material resources.10 The key measure of material resources is personal or household income. Housing tenure and car access have often been used as indicators of material resources when a direct measure of income has not been available.11,12 Limited material resources may restrict possibilities to take part in some healthy behaviours. However, this does not seem to apply to smoking, since non-smoking is always the cheapest alternative.5,13,14 Furthermore, if smoking depended only on spending power, those with limited material resources should be smokers less often than those with more resources, but income and other measures of material well-being are inversely associated with smoking.4,14,15 It is possible, however, that the association between material resources and smoking is confounded by other dimensions of socioeconomic position. If the other dimensions of socioeconomic position were taken into account, the inverse income gradient might be reversed.
The economic explanation that emphasizes spending power and consumption opportunities seems not to be a sufficient explanation for the association between poor material resources and smoking. Another explanation suggests that people may smoke as a response to stress induced by unfavourable socioeconomic circumstances.5,16 Those who live in poorer socioeconomic circumstances may more often have stressful situations. Furthermore, better material resources may provide easier access to alternative ways of coping with disadvantage and stress than smoking.5,13 Measures describing how people themselves see their economic situation may therefore provide additional information on socioeconomic differences in smoking.
The available information on socioeconomic differences in smoking largely concentrates on describing the differences and their temporal trends by one socioeconomic indicator at a time. While some studies have examined the differences using several parallel indicators, few attempts have been made to disentangle the various dimensions of socioeconomic position.17–19 In order to separate the different dimensions, several socioeconomic indicators have to be examined at the same time. This study contributes to the research on socioeconomic patterning of smoking by examining simultaneously three dimensions of socioeconomic position, each measured with two indicators: education and occupational status describe the basic structural position in socioeconomic hierarchy; household income and housing tenure measure related material resources; and economic difficulties and economic satisfaction describe the respondent's perceived economic situation. Furthermore, the different socioeconomic dimensions are causally successive: structural socioeconomic position partly determines the material living conditions, which in turn may contribute to the perceived economic situation. By taking the temporal order of the dimensions into account, this study aims to illuminate the potential pathways through which socioeconomic position may relate to smoking among men and women.
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Methods |
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Data
The data derive from an ongoing Helsinki Health Study20 that focuses on socioeconomic and other determinants of health and well-being among middle-aged men and women employed by the City of Helsinki. The City of Helsinki is a large employer with nearly 40 000 people in its service. In addition to general administration, most people work in social and health care, education and culture, public transport and in technical and construction branches.
This study used pooled data from two separate cross-sectional surveys conducted in 2000 and 2001. The personnel register was used to identify all employees of the City of Helsinki, and a self-administered questionnaire was sent to each employee who reached the age of 40, 45, 50, 55 or 60 during the year of the survey. The data include altogether 1252 men and 4991 women. The response rate was 62% for men and 70% for women. The respondents represent the target population reasonably well in terms of sociodemographic characteristics.21
Measures
Smoking status was determined by the answer to the question: ‘Do you currently smoke cigarettes, cigars or pipe on a regular basis?’ with the two response alternatives of ‘yes’ or ‘no’. The proportion of smokers was 29% among men and 22% among women. These figures correspond to the national averages in the same age group.22
Educational level was measured by a question asking about completed general or vocational education. Education was divided into three groups corresponding to (i) basic (compulsory) education, (ii) secondary education and (iii) higher education (university degree). The respondent's occupation was derived from the personnel register of the City of Helsinki if written permission was received from the respondent (77%). Otherwise, information on occupation was coded from the questionnaire. Four hierarchical occupational status groups were formed: (i) managers and professionals, (ii) semi-professionals, (iii) routine non-manuals and (iv) manual workers.
The respondents were asked to report their household income during a typical month, excluding taxes and including any welfare benefits received. The number of persons living in the household was taken into account by assigning weights of the modified OECD equivalence scale: the respondent 1, other adults 0.5 and children 0.3.23 The resulting figure that better describes the respondents' material standard of living was divided into quartiles. Another indicator of material socioeconomic position was housing tenure, which was divided into four categories: (i) owner-occupier, (ii) free-market renter, (iii) renter from the employer (the City of Helsinki) and (iv) other.
Economic difficulties were elicited by two questions: ‘How often do you have enough money to buy the food or clothing you or your family need?’ and ‘How much difficulty do you have in meeting the payment of bills?’ Both questions had five response alternatives. These two questions were combined into one sum indicator with three categories indicating: (i) no economic difficulties, (ii) occasional economic difficulties and (iii) frequent economic difficulties. Economic satisfaction was assessed by asking satisfaction with one's standard of living. Originally seven response alternatives, ranging from very satisfied to very dissatisfied, were collapsed into three groups: (i) satisfied, (ii) somewhat satisfied and (iii) dissatisfied.
Two potential confounders were adjusted for in the analyses. Age was included in five original categories. Marital status was grouped into four categories: (i) single, (ii) co-habiting, (iii) married and (iv) divorced, separated or widowed. The distributions of the socioeconomic indicators and the potential confounders are presented in table 1.
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Table 2 shows intercorrelations between the socioeconomic indicators. All socioeconomic indicators were modestly to strongly correlated (P<0.001). Because education and occupational status were very closely associated, the analyses were repeated using only one of these indicators. The association between the remaining indicator and smoking became stronger, especially in women, but otherwise the results remained similar. Therefore, only the results including all six socioeconomic indicators are reported here.
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Statistical methods
All analyses were performed separately for men and women. We first present the prevalence of smoking by each socioeconomic indicator. Differences between the socioeconomic groups were tested by chi-square analysis.
Logistic regression analysis was used to examine how several socioeconomic indicators were simultaneously associated with smoking. Sequential models where one indicator at a time was added to the previous model were fitted. Each of the socioeconomic indicators was first included individually. Then we added to the models the structural indicators (education and occupational status), after that the material indicators (household income and housing tenure) and finally the indicators of perceived economic situation (economic difficulties and economic satisfaction). In this final model all socioeconomic variables were mutually adjusted for each other. The order of modelling corresponds to the assumed temporal order between the socioeconomic indicators. The intercorrelations presented in table 2 also support this order of modelling: the further the socioeconomic indicators are from each other, the weaker their correlation tends to be. All analyses were adjusted for age and marital status. The results are presented as odds ratios and their 95% confidence intervals. For each socioeconomic indicator the most advantaged group was selected as the reference category.
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Results |
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All socioeconomic indicators were strongly associated with smoking in both men and women (table 3). Smoking was more common among those with lower education and income. In men, routine non-manuals and manual workers smoked more often than semi-professionals or managers and professionals. In women, smoking increased systematically from managers and professionals to manual workers. Both groups of renters smoked more often than owner-occupiers. Smoking was more common among those who reported economic difficulties and economic dissatisfaction.
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Table 4 presents the results from the sequential logistic regression models for men. The first column shows the association between each socioeconomic indicator and smoking individually. When the structural indicators, education and occupational status, were included in the model simultaneously both were associated with smoking more weakly than when examined individually. Only routine non-manuals statistically significantly differed from managers and professionals. Adding income to the previous model further attenuated the associations between the structural indicators and smoking; also, the association between income and smoking weakened. Adding housing tenure to the model again attenuated the associations between the structural indicators and smoking. Economic difficulties had no influence on the associations between the structural indicators and smoking, and only slightly attenuated the associations between the material indicators and smoking. The association between economic difficulties and smoking disappeared. Economic satisfaction had a similar effect to economic difficulties: it had no influence on the structural indicators and only slightly attenuated the associations between the material indicators and smoking. When all socioeconomic indicators were mutually adjusted for, only housing tenure and economic satisfaction reached statistical significance.
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In women, the associations of education and occupational status with smoking were clearly attenuated when these indicators were examined simultaneously (table 5). However, both indicators continued to show a strong inverse association with smoking. Income had no effect on the associations between the structural indicators and smoking, but housing tenure slightly weakened the association between occupational status and smoking. Income showed no association with smoking in the model that included education and occupational status, and also the association between housing tenure and smoking was weaker than when examined individually. The indicators of perceived economic situation turned the association between income and smoking slightly to the positive and weakened the association between housing tenure and smoking somewhat, but they had no effect on the associations between the structural indicators and smoking. Economic difficulties were associated with smoking even when the structural and the material indicators were included, but adjusting for economic satisfaction made this association statistically non-significant. Economic satisfaction remained associated with smoking after adjusting for all other socioeconomic indicators. In the final model, all indicators except economic difficulties were inversely associated with smoking, and the association between income and smoking was slightly positive.
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Discussion |
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Smoking is a major public health problem that shows clear socioeconomic differences. Few previous studies have analysed socioeconomic differences in smoking by simultaneously taking into account several different indicators of socioeconomic position. In this study we examined socioeconomic differences in smoking by using two structural indicators, two material indicators and two indicators of perceived economic situation.
When studied individually, all socioeconomic indicators showed a strong association with smoking. Smoking increased gradually from the higher to the lower socioeconomic groups, irrespective of the indicator used. The only exception was occupational status in men, as routine non-manuals tended to smoke more often than manual workers. Since such a divergence was not observed with the other socioeconomic indicators, the probable explanation for this finding is that there are some relatively large heavy smoking occupations, such as (mental health) nurses, that fall into this occupational status category.
Examining several socioeconomic indicators simultaneously attenuated their associations with smoking. In the final models, where all socioeconomic indicators were mutually adjusted for, housing tenure and economic satisfaction remained associated with smoking in men. In women, most indicators were associated with smoking after all adjustments. The largest changes occurred when education and occupational status were adjusted for each other and when the material indicators were introduced in the models already containing the structural indicators. Instead, the indicators of perceived economic situation had only modest effects on the associations of the structural and material indicators with smoking.
The associations between socioeconomic indicators and smoking were broadly similar among men and women. When each socioeconomic indicator was examined individually, differences by education and occupational status were larger among women than men, whereas men showed more variation by income and economic satisfaction. After adjusting the indicators for each other more indicators remained associated with smoking among women. This is partly because the data included more women than men. However, it may also be that more indicators are needed to accurately describe socioeconomic position among women, as their social circumstances are shaped by their structural and material position but also by their marital and parental roles.24,25
The data came from a homogeneous cohort of middle-aged, urban employees where information on various socioeconomic indicators was available. However, the data also have limitations. First, information on both smoking and socioeconomic indicators was self-reported. However, previous studies suggest that self-reports of smoking are rather reliable26 and that socioeconomic differences in the reporting bias are small.27 The respondents may also have considered some questions on their socioeconomic circumstances as too personal which may have affected their answers. However, few people left the socioeconomic questions unanswered, which suggests that major bias in this respect is unlikely. Second, the data derived from cross-sectional surveys where the socioeconomic information was asked simultaneously with smoking. Therefore, strict causal judgements should be avoided. Since regular smoking is a rather costly habit it may increase economic difficulties rather than the difficulties being an incentive for smoking. In contrast, smoking does not directly influence the other socioeconomic indicators examined in our study. Although selection cannot be entirely ruled out, we assume that the order of the association runs mainly from the socioeconomic indicators to smoking.
Along with the other socioeconomic indicators, income showed a clear inverse association with smoking. The association was markedly attenuated when education and occupational status were adjusted for, which suggests that the differences between income categories largely reflect the differences in smoking by one's structural position. This finding is comparable to a previous study.14 In the present study, the inverse association between income and smoking was further weakened in men, and in women turned positive, by the indicators of perceived economic situation. This suggests that economic difficulties and economic satisfaction partly explain the inverse association between income and smoking. Moreover, in both genders economic dissatisfaction remained strongly associated with smoking even when all other socioeconomic indicators were adjusted for. This implies that subjective appraisal of one's economic situation may be an important determinant of smoking even independently of the more objective measures of socioeconomic position.
In our study, housing tenure was adopted as a further indicator of material resources in addition to income. While income is usually measured at one point in time, housing tenure is rather an indicator of cumulative prosperity and wealth.28 Both income and wealth may be linked to health behaviours by providing spending power and consumption opportunities. However, while the inverse association between income and smoking disappeared when the socioeconomic indicators were mutually adjusted for, housing tenure continued to show a strong association with smoking. Apart from being an indicator of material resources, housing tenure could have direct effects that promote smoking.29–31 Being a renter could mean poorer housing conditions or adverse neighbourhood characteristics. However, in Finland differences in housing conditions between owner-occupied and rented housing are quite small.32 Neither are forms of housing tenure strongly segregated by living area, but attitudes towards smoking could differ between individual blocks, and more middle class houses may apply stricter smoking regulations.
During the last few decades the overall prevalence of smoking has decreased, at least in men, but this has happened at the expense of widening socioeconomic differentials. In Finland, as well as other parts of Europe, smoking is clearly more prevalent in lower socioeconomic groups.33,34 Development of antismoking measures that are effective among the socioeconomically disadvantaged would be important not only for narrowing the gap between the socioeconomic groups, but also because they offer the greatest potential for reducing the prevalence of smoking in the whole population as well. However, so far few preventive measures have been socioeconomically targeted in Finland35 or elsewhere.36 This study confirms that socioeconomic differences in smoking are a complex and multi-faceted phenomenon. Smoking is related to structural, material as well as perceived dimensions of socioeconomic disadvantage. However, none of the dimensions stands out as definitely the most important. The influence of the structural indicators does not go entirely through the material and perceived dimensions of socioeconomic position, which in turn do not only reflect the structural dimension of socioeconomic position. In attempts to reduce smoking among the socioeconomically disadvantaged, efforts directed at various dimensions of socioeconomic position are needed.
Key points
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Acknowledgments |
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Helsinki Health Study is supported by grants from the Academy of Finland (#53245) and the Finnish Work Environment Fund (#99090). We thank the City of Helsinki and all members of the Helsinki Health Study Group.
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