The European Journal of Public Health Advance Access originally published online on March 12, 2007
The European Journal of Public Health 2007 17(6):565-571; doi:10.1093/eurpub/ckm010
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Socioeconomic Inequalities in Health |
Trends in socio-economic differences in tobacco smoking among German schoolchildren, 1994–2002
Matthias Richter1 and Anja Leppin2
1 School of Public Health, University of Bielefeld, Bielefeld, Germany
2 Department of Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
Correspondence: Dr Matthias Richter, University of Bielefeld, School of Public Health, PO 10 01 31, 33501 Bielefeld, Germany, tel: +49 (0) 521.106-3878, fax: +49 (0) 521.106-6433, e-mail: matthias.richter{at}uni-bielefeld.de
Received September 24, 2006, accepted January 24, 2007
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Abstract |
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Background: While the graded relationship between socio-economic status (SES) and risk behaviour in adulthood has been the subject of intense research, far less is known about socio-economic differences in health-related behaviour among adolescents. The purpose of the present study is to examine socio-economic differences in adolescent tobacco use in Germany as well as changes in the relationship between 1994 and 2002. Methods: Data were obtained from the ‘Health Behaviour in School-aged Children’ study conducted in the largest federal state of Germany, Northrhine-Westfalia, in 1994, 1998 and 2002. The analysis is based on 11.401 11- to 15-year old students. Socio-economic differences in regular smoking were studied in relation to both parental SES (family affluence) and students own SES (school type). Trends from 1994 to 2002 were analysed for each category of family affluence and school type separately. Results: Family affluence only had a weak effect on regular smoking while for type of school a strong social gradient for smoking was found for both the genders. Trend analyses within the different family affluence and school-type categories showed that smoking has generally increased in all socio-economic groups. The level of socio-economic differences remained virtually unchanged in girls and boys in the past 10 years in Germany. Conclusions: The same relationships of family affluence and school type with smoking have persisted for almost a decade in Germany. Students own SES affects adolescent smoking substantially. Prevention programmes should focus on the school setting in order to tackle current as well as future health inequalities.
Keywords: adolescence, smoking, socio-economic status, trends, HBSC, Germany
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Introduction |
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Numerous studies have shown that socio-economic status (SES) has a profound influence on health.1,2 One major factor contributing to these health inequalities are risk behaviours, such as smoking, malnutrition, excessive alcohol consumption and lack of physical activity.3–8 Many of these behaviours are established in adolescence and produce a variety of undesirable health outcomes as early as adolescence.9–11 However, while the graded relationship between SES and health risk behaviours in adulthood has been the subject of intense research, far less is known about the magnitude and the pattern of socio-economic differences in health-related behaviours among adolescents in Europe in general and Germany in particular.12–14 This lack of research effort is particularly surprising as evidence of such an early life-course relationship between socio-economic differences and health risk behaviours would be a matter of concern and would constitute a particular challenge for health and social policy.
In addition, the limited evidence on the relationship between socio-economic status and health risk behaviours in adolescence that does exist is inconsistent and even contradictory.15–17 This is especially true for tobacco smoking, which still represents a major public health concern in Europe. While some researchers found no or only slight socio-economic differences,15,18–22 other studies have identified an unequal distribution of adolescents’ smoking behaviour among socio-economic groups.23–27 Nevertheless, the fact that studies in adult populations show strong and persistent social gradients in tobacco smoking indicates an increasing relationship between smoking and SES with age and points to an ‘adolescent emergent pattern’ of socio-economic differences in tobacco use.16
Germany is one of the countries with the highest rates of adolescent smoking in Europe.28 From a public health perspective it is thus important to study changes in risk behaviours over time in order to set priorities and to develop adequate preventive strategies. The aim of the present article is to investigate (1) whether socio-economic differences in tobacco smoking can be found among adolescents in Germany, (2) whether the relationship between SES and this risk behaviour changed over time and (3) whether differences in the association between SES and smoking behaviour can be found according to parental and adolescents’ own socio-economic status.
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Methods |
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The analysis was based on data from the German part of the ‘Health Behaviour in School-aged Children (HBSC): A WHO Collaborative Cross-national Study’. The aim of the HBSC study is to describe young people's health and health behaviour and to analyse how these outcomes are related to the social context. Cross-sectional surveys of 11-, 13- and 15-year-old adolescents are carried out every four years in a growing number of countries based on an internationally agreed protocol. The latest survey, in 2001/02, included a total of 35 countries from Europe and North America. A detailed description of the aims and theoretical framework of the study can be found elsewhere.28,29
Germany is a member of HBSC since 1994. The first two surveys (1994 and 1998) were limited to Northrhine-Westfalia, the largest federal state of Germany with 18 million residents. The latest study was conducted also in the federal states of Hesse, Berlin and Saxony. The data presented here are from three consecutive HBSC surveys conducted in Northrhine-Westfalia in 1994, 1998 and 2002.
Sample
All surveys used identical protocols considering target group, sampling, and data collection. In each of the three waves the sample was drawn by systematic cluster sampling (schools), stratified by administrative district and type of school. The numbers of sampled schools were 81 in 1994, 62 in 1998 and 119 in 2002. According to the international HBSC research protocol only 11, 13 and 15-year olds were interviewed. The fieldwork took place in early springtime of each year. The total numbers of pupils participating in the surveys in 1994, 1998 and 2002 and providing usable data were 3275, 4792 and 3334, respectively. The study was totally anonymous and thus it was not possible to conduct an individual non-response analysis. The age and sex distribution of participants was similar in all three surveys. Further details of the German HBSC study can be found elsewhere.30 Table 1 shows the characteristics of the three different samples. Only students whose parents had signed an informed consent form were included in the study. The study was approved by the federal data protection commission.
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Instrument and variables
Data were collected by means of a standardized questionnaire. A strong effort has been made to retain a core of items in each survey to facilitate the monitoring of trends.29,31,32 Teachers administered the questionnaires in the classroom and were instructed to answer questions about procedure only. After completion the students were asked to put the questionnaire in an envelope, close it and hand it over to the teacher.
Tobacco smoking
Smoking status was defined on the basis of the question ‘How often do you smoke tobacco at present?’ Possible responses were: ‘every day’, ‘at least once a week, but not every day’, ‘less than once a week’ or ‘never’. Adolescents who smoked at least once a week were considered regular smokers.33
Family affluence
Parental socio-economic status was measured using the Family Affluence Scale (FAS).34,35 This scale is a validated measure of material affluence derived from the characteristics of the household and consists of three items that adolescents can readily answer: Does your family own a car (0, 1, 2 or more), how many times did you travel away on holiday with your family during the past 12 months? (0, 1, 2, 3 or more), and do you have a bedroom for yourself? (no = 0, yes = 1). Because of the different measurement levels of the items, a categorical principal components analysis (CATPCA) was done as suggested by Batista-Foguet and colleagues.36 The joint score was subsequently recoded into tertiles of high, middle and low family affluence.
Type of school
In addition, type of school has been included in the analysis, as an indicator of the students’ own SES. In Germany four school types exist at the secondary level, which offer education programs of varying length, depth and emphasis: the most basic type is secondary general school (Hauptschule), followed by the relatively more advanced intermediate school (Realschule), and the most advanced grammar school (Gymnasium), which leads to the examination that qualifies for university education (Abitur). The only school type that does not fit completely into this hierarchical system is comprehensive school (Gesamtschule), which unites students of all levels of ability under one roof and offers options for all three ‘tracks’ above. However, usually it is considered to rank somewhere between intermediate and grammar school. The allocation of students to the different school types generally takes place after grade 4. The decision is based on a performance assessment by the elementary school teachers, but parents have to be consulted and the final decision is supposed to be a joint one.
Statistical analysis
Time trends for the percentages of regular smokers were estimated with the help of logistic regression models. Survey year was included in the model as a series of dichotomous ‘dummy’ variables. Results are presented as Odds Ratios and 95% confidence intervals. These analyses as well as all the following ones were done separately for both genders. Effects of age (dummy coded with three age groups: 11, 13 and 15) were controlled for in each analysis. Differences in smoking according to family affluence and type of school were analysed for the total sample as well as each period (1994, 1998 and 2002). For this purpose, age-adjusted odds ratios and corresponding 95% confidence intervals were calculated using logistic regression. In each model the highest group (i.e. high family affluence and grammar school) served as the reference category with odds ratios being computed for the other two (family affluence) or three (type of school) groups in comparison. In addition, for each category of family affluence and school type time trends were computed separately, in order to estimate for each group whether there had been significant changes from 1994 to 1998, 1998 to 2002 as well as over the whole time span from 1994 to 2002. All statistical analyses were done using SPSS, version 12.0. To take into account the possible effect of cluster sampling, robust standard errors were re-estimated using STATA. All reported odds ratios and 95% confidence intervals are based on robust standard errors.
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Results |
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Prevalence and trends
Table 2 presents the prevalence of regular smoking by gender and the three survey years. From 1994 to 2002 rates for smoking have increased for 11–15-year old girls and boys. While in 1994 the percentage of regular smokers was 11.1%, in 2002 15.2% of young adolescents reported smoking at least once a week. The main increase in the rate of regular smoking—particularly for girls—has taken place during the 90s.
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Socio-economic differences in smoking: prevalence and trends
Table 3 shows the results of the separate logistic regression models on the effect of family affluence on tobacco smoking. For none of the three male cohorts a significant effect of family affluence on regular smoking could be found. The only exception was in 1994 where an increased odds ratio was observed for boys from low affluent families. From 1994 to 2002 all three FAS subgroups added to their contingent of regular smokers, with the bulk of the increase taking place between 1994 and 1998. While this gain was largest in the initially least afflicted subgroup, boys from a high affluent background whose percentage of regular smokers doubled from 1994 to 2002, the somewhat smaller increase of 80% in the low FAS group was still significant. For the medium FAS the rates of regular smokers significantly increased from 1994 to 1998 but then decreased again from 1998 to 2002. The overall trend for this group was thus U-shaped and not significant. In 2002, rates of regular smokers ranged from 16.0% in the high and 12.4% in the medium to 17.9% in the low FAS group.
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For girls a similar inconsistent picture was found. Only in 1998 girls with a low affluent family background exhibited more unfavourable smoking rates than girls from high affluent families. Adjusted for age, the risk of regular smoking increased from 1.16 in the medium FAS group to 1.61 in the lowest group. By 2002, however, these differences had become smaller and did not reach significance any more. The decreasing importance of family affluence over time was also reflected in the fact that from 1994 to 2002, all three FAS groups seem to have expanded their smokers’ contingent by about 30%, even if this increase in rates did not become significant. When only the development from 1994 to 1998 was taken into account, there was a significant 43% increase among low affluent girls. High and medium affluent girls also increased their rates by
30%. In contrast, the time span between 1998 and 2002 witnessed a decrease in low affluent girls, while the other groups remained stable. However, all these effects were non-significant. When school type was used as an indicator of students’ own socio-economic status instead strong and distinct effects on regular smoking for boys as well as for girls appeared (table 4). For both genders and in each of the three cohorts, a pronounced social gradient in regular smoking was observed. Particularly students from general schools, which represent the lowest educational level, faced an average risk of about 4 times that of the group from the highest educational level. But even students from medium and comprehensive schools had an elevated risk between 2 and 3 on average.
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Looking at ‘inequalities in trends’ between the separate educational groups demonstrated, that for girls the overall increase in smoking over time was due to the two groups at the medium educational level. Both, female students in intermediate as well as comprehensive schools exhibited higher smoking rates in 1998 than in 1994; and in both groups these proportions have decreased since. Thus, the female intermediate school students ended up at about the same percentage level of 12–14% they had started out with. Only for comprehensive school students there was still a significant increase over the whole time span. Female grammar school students as well as those from general schools have withstood any trend—starting, however, from very different baseline levels, i.e. low versus high. For boys, the picture looked somewhat different. Here, with the exception of boys from comprehensive schools, all other groups have—particularly between 1994 and 1998—increased their rates of regular smokers at a significant level.
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Discussion |
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Summary of the results
To our knowledge this study is the first to examine trends in socio-economic differences in smoking among adolescents in a European country. The results show that from 1994 to 2002 regular smoking among 11–15-year olds in Germany has increased and that this effect was largely independent of family affluence and type of school—although there were differences in terms of degree and whether changes took place sooner or later. Looking at the cross-sectional results, only in one of the three cohorts a significant effect of family affluence on regular smoking was found, for boys in 1994 and for girls in 1998. Also when all cohorts were combined low affluent boys as well as girls had slightly higher smoking rates than high affluent adolescents. A completely different picture emerged when type of school was used as a measure of students’ own SES. Educational level of students seems to be of major importance in the prediction of smoking patterns among German adolescents. For both genders as well as all cohorts, a strong social gradient for smoking was found for all three regular school types.
Study limitations
Several methodological problems need to be acknowledged. Self-report data on substance use generally relate to a normatively loaded topic. The particular problem here might be an uneven distribution of social desirability effects among different social groups. Assuming that social desirability is more likely to occur in adolescents from a more advanced social background, as their parents smoke less and more often use smoking bans at home,37 this group might underreport smoking behaviour, which again would lead to an overestimate of socio-economic differences in tobacco use. Unfortunately, it is unknown to what degree such mechanisms are actually at work in adolescence and whether such an effect is substantial or negligible. However, three arguments suggest that a bias due to self-reporting is limited. First, the overall prevalence of smoking in this study is consistent with recent studies among German adolescents.38 Also, while dichotomous classifications of smoking might be considered somewhat crude, such classifications are less vulnerable to reporting errors. Lastly, in order to underline the importance of honest responses, students were assured of the anonymity of the study and that neither their parents nor teachers would find out about individual answers.
The finding that family affluence has a weaker effect on smoking than type of school might also leave doubts as to whether family affluence is a valid indicator of parental SES. However, several studies have shown that family affluence has a profound effect on various measures of health and health behaviours such as self-rated health, physical activity and dietary behaviour using individual as well as country level data.39–41 In addition, the country level of FAS is strongly correlated with macro-economic and population health indicators.42 Also, in another study based on recent German HBSC data similarly weak socio-economic differences for smoking were found using occupational status as a parental SES measure.13 Given these findings, it is not likely that the presented results are severely biased by the use of family affluence as a parental SES indicator.
However, it should be acknowledged that studies among adult populations have shown that education and occupational status are more strongly associated with smoking than income.43 Family affluence measures only one aspect of SES, which is much more related to income, material wealth and spending patterns. Therefore, it might also be presumed that the differing effects of affluence and type of school on smoking could be due to a differential impact of sub-dimensions of SES, i.e. income versus education, rather than on parental versus adolescents’ social status alone.
Comparison with previous research and interpretation
Unfortunately, comparable data on socio-economic differences in smoking are non-existent for Germany. But our finding of no or small socio-economic differences in tobacco smoking using a parental SES measure underlines previous studies from countries such as England,19 Scotland,22 France,20 Italy18 or the Netherlands.15 However, it has also to be stated that studies among adolescents from the US,24,27 Northern Ireland,25 Slovakia,26 and the Netherlands23 did show clear socio-economic differences regarding tobacco use. Although all these studies have used similar methods no concise socio-geographical patterns emerged. Data from the latest international HBSC survey which has been using the same design, age groups and measures in all participating countries, also showed inconsistent results. Weekly smoking was associated with family affluence for girls in 13 and for boys in 6 out of 35 countries without any discernible geographical or cultural pattern. One systematic finding, however, seems to be an increasing relationship between tobacco use and SES with age,22,44 indicating an ‘adolescent emergent pattern’ of socio-economic differences.16
In addition, our results support findings of various studies, which show that smoking is more strongly linked to students’ own social status than to their familial background.22,45–47 Thus, a Finnish study showed that smoking at the age of 15 years was strongly related to own socio-economic status 13 years later, while various measures of parental SES were not associated with smoking in adolescence nor in adulthood.48 Nevertheless, it might still be questioned whether students really have their independent SES—or in this case educational status—at the age of 11 or 15 years. On one hand Germany has a very differentiated school system and the extent of mobility processes after this initial decision is limited, so that the early assignment to a specific school track predicts later socio-economic trajectories, i.e. adult income and/or job position, to a considerable extent.49,50 These arguments support the idea of an adolescents’ own SES. On the other hand, does the assignment to different school tracks not occur independent of parents’ SES. We found a significant, if only small to medium-sized correlation between family affluence and type of school (r = 0.28), indicating that children from high affluent families are more likely to end up in the higher ranges of the school system. The German PISA-study, which also looked at other SES indicators found that children from higher occupational classes had a four times higher chance to attend a grammar school than did low status children.51 Two processes might explain this discrepancy: children from a more favourable socio-educational background are more likely to perform well in elementary school due to a higher degree of support and stimulation from home. Additionally, as parents have to be consulted for the transfer decision, those from a high SES background are more likely to lobby on behalf of their children attending the higher strata of the school system even when school performance is more ambiguous. So, while parental SES might have limited direct impact on adolescent smoking it has additional indirect effects by influencing type of school attended. This interpretation is also suggested by the fact that when type of school was controlled for in those analyses which tested for effects of family affluence, the few and small effects found for family affluence were further reduced.
While the strong association between school type and regular smoking might also be the effect of selection processes resulting from differential home environments and reflect different social norms and parental modelling behaviours related to smoking, the specific school environments could also have independent effects on smoking. With increasing age the influence of family background on adolescents decreases while the influence of peers increases.14,16 School type might thus largely represent effects of differential peer clusters, as students from high SES parents are more likely to gather in grammar schools while those from a disadvantaged background face a higher probability of meeting up in general school. Also school-related factors such as achievement motivation and school performance tend to differ among school types.52 The combination of peer clusters from a similarly unfavourable social background with a higher likelihood of performance problems and adverse employment perspectives on a strained German labour market which holds few job offers for young people with low education is likely to create a ‘school-alienated’ peer climate53 that might be a considered a risk factor for health-compromising behaviours such as smoking.
Whether these processes on the whole are the outcome of an independent adolescent social status is thus debatable. What can rather be assumed at work here are additive and cumulative mechanisms which create socially differential socialization pathways into tobacco consumption from childhood to adolescence where the parent's SES and related modelling behaviours and social norms also determine children's educational tracks. These are likely to reinforce prior influences and thereby put children from disadvantaged backgrounds not only at risk for a poorer academic education and subsequently worse perspectives in terms of their future occupation and income but also in terms of adverse health behaviours such as smoking.
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Conclusions |
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The results of this study show that parental SES is only of minor importance for the prediction of smoking patterns among German adolescents. In comparison, students’ educational level has a profound effect on regular smoking for both genders. Furthermore, smoking trends over a time period of almost 10 years did not differ between the different levels of family affluence and type of school. The general increase in smoking occurred more or less in all socio-economic groups. Considering the marked effects of school type on smoking preventive and health promoting actions should focus on the context of schools, especially in general and intermediate schools, in order to reduce SES differences in smoking in later life.
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Acknowledgements |
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The ‘Health Behaviour in School-aged Children (HBSC)’ study is an international survey conducted in collaboration with the WHO Regional Office for Europe. The current International Coordinator is Candace Currie, CAHRU, University of Edinburgh and the Data Bank Manager is Oddrun Samdal, University of Bergen. The authors would like to thank three anonymous referees for their advice and comments on a early version of this article.
Conflicts of interest: None declared.
Key points
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