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Social determinants of ever initiating smoking differ from those of quitting: a cross-sectional study in Estonia

Mall Leinsalu, Mare Tekkel, Anton E. Kunst
DOI: http://dx.doi.org/10.1093/eurpub/ckm030 572-578 First published online: 2 April 2007

Abstract

Background: To study the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-oriented tobacco control policies. Methods: Data for 4277 individuals in the 25–64 age group come from three cross-sectional studies conducted in 2000, 2002 and 2004. Age-standardized prevalence rates and odds ratios with 95% confidence intervals were calculated. Results: High rates of ever initiation were observed for lower educated men and women after controlling for other socioeconomic indicators. This association was not observed for women above age 50. Independent, although weaker associations were found among men who were unemployed or with a low occupational status. Low cessation rates were observed among men who were unemployed, who had a lower occupational position or who had a low income. These associations remained after controlling for other socioeconomic variables. The effect of income became stronger in the older age groups among men. Rates of ever initiation and cessation also varied strongly in relationship to some demographic variables. The highest initiation rates were found among divorced women and among women living in the capital city. The lowest cessation rates were found among divorced women, and among Russian men. Conclusions: While educational level was the strongest predictor of ever initiating regular smoking, smoking cessation was related more directly to aspects of social disadvantage originating in adult life. To be effective, tobacco control interventions should not only target lower educated, but also those in material disadvantage.

  • Estonia
  • ever regular smoking
  • smoking cessation

Introduction

Tobacco smoking and smoking-related diseases are important causes of premature death1 and have a large impact on socioeconomic inequalities in health in developed countries.2,,3 Socioeconomic inequalities in smoking have been extensively documented for the Western European countries.4–6 In Central and Eastern Europe, and in the former Soviet republics in particular, the burden of smoking-attributable mortality is high.1 In the former Soviet republics smoking prevalence is very high among men but relatively low among women amongst whom smoking is generally more common in the younger age groups and for those living in urban areas.7–11 These studies suggest that there is a positive relationship between social disadvantage and smoking among men, whereas this relationship is far less consistent for women.

Previous research on social inequalities in cigarette use in the former Soviet republics has relied on assessments of current smoking.7–11 The prevalence rate of current smoking is the result of different processes over the entire life course, namely initiation, continuation and cessation of smoking.12 Compared to prevalence, smoking initiation and cessation measure the change in cigarette consumption and may therefore be more relevant indicators for tobacco control policies. In addition, the social determinants of smoking initiation may differ from those of smoking cessation.

Studies on socioeconomic differences in smoking initiation or cessation have often used the individual's educational level as the single measure of social position.13–15 Educational level is an important indicator of social position over the life course, however, indicators of socioeconomic position achieved in adulthood, such as occupation, income or unemployment, but also broader indicators that capture a person's social position may be equally helpful in understanding inequalities in smoking. In Estonia, ethnicity, rural vs. urban place of residence and marital status were found to be important predictors of self-rated health or mortality.16–18 It is of interest, therefore, to examine the relations of these indicators to smoking. Examining several socioeconomic and demographic indicators at the same time helps to disentangle the effects of the different dimensions of social position.19

This study aims to analyse the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-orientated tobacco control policies. This approach together with the simultaneous use of different socioeconomic indicators may be particularly useful in guiding the research and tobacco control policies in Eastern Europe where the burden of tobacco-related health problems is high and where social inequalities in health are widening.18,20,,21

Methods

Study population

The data come from the Health Behaviour Survey of the Estonian Adult Population, a cross-sectional study that is part of the FINBALT Health Monitoring project described in detail elsewhere.22 The project uses a common study design in all participating countries and across the whole study period. In Estonia, the survey has been conducted in the form of a postal interview every second year since 1990. We combined data sets from three surveys conducted in 2000, 2002 and 2004 in order to increase the statistical power. A simple random sample of the Estonian population aged 16–64 years was drawn from the population register for each survey. The percentage of completed and returned interviews was 67% in 2000 (n = 1376) and 2002 (n = 1338), and 62% in 2004 (n =3074).23–25 The age-structure of the respondents in the combined data set was highly comparable with the age-structure of the Estonian population of 1 January 2004; except that the age group 60–64 was slightly over-represented in the survey data. From this data set we excluded all cases (n = 546) where data were missing or incomplete for gender, age or smoking-related variables. We did not observe large differences between the excluded data set and the main sample when sociodemographic characteristics were compared. The data analysed below included 4277 persons aged 25–64 years. The item non-response in the studied sample varied from 0.4% (n = 19) for marital status to 2.5% (n = 106) for income, and 3.1% (n = 131) for economic activity.

Outcome variables

Initiation of regular smoking was measured by the percentage of ever regular smokers among all respondents. Regular smoking refers to smoking almost every day for at least one year.

Cessation of smoking was measured by the percentage of quitters among ever regular smokers. Among quitters 1.7% had stopped smoking less than one month ago and 6% had stopped smoking 1–6 months ago.

Independent variables

For marital status respondents were classified into three groups: married or cohabiting, never married, and divorced, separated or widowed.

For the place of residence we distinguished three groups: respondents living in the capital city Tallinn, respondents living in other cities and those living in rural areas.

Ethnicity refers to self-reported national identity. The two largest ethnic groups in Estonia, Estonians and Russians are distinguished in the analysis.

Educational level is divided into three categories. Higher education refers to tertiary education. Secondary education combines general and specialized secondary education with 10–12 years of schooling as average. Basic education or less refers to receiving a maximum of 9 years of schooling.

The measure of economic activity classified students, military conscripts, homemakers or the retired as economically non-active. For the economically active, a distinction was made between the employed and the unemployed.

Occupational classification is applied to persons who were employed at the time of the survey. The higher non-manual occupational class consists of managers, higher and associate professionals, the lower non-manual group consists of clerks and sales or service workers, the third group is composed of skilled workers while the final group combines semi-skilled and elementary occupations.

Household income is based on the question ‘What was the average monthly income per family member during the last 12 months?’ with ten pre-defined answer categories (12 in 2004). The pre-defined income groups in each year were divided into high, medium and low income groups of a roughly comparable size in terms of the percentage distribution of all respondents.

Statistical analysis

Data were analysed separately for men and women, for all ages combined and for three age groups: 25–34, 35–49 and 50–64. Absolute differences were evaluated by calculating age-standardized prevalence rates. Direct standardization was performed by using 5-year age groups with the total population of Estonia on 1 January 2004 as the standard population. Relative differences were evaluated by means of logistic regression using the SPSS 13.0 statistical package.26 The effect of each social variable was measured in both univariate (Model 1) and multivariate (Model 2) models. Both models were age-adjusted by including 5-year age groups. The results are presented as odds ratios with 95% confidence intervals.

Results

In our sample, 81% of men and 46% of women had initiated smoking at some point in time in their life. Of them, 90% became regular smokers among men, whereas among women it was 80%. Twenty seven percent of male and 33% of female regular smokers had managed to quit smoking by the time of the survey. As a result of these processes, the prevalence of current regular smoking was 51% among men and 21% among women.

The associations between the socioeconomic and demographic variables and smoking initiation in the 25–64 age group are presented in table 1. Having a low educational level was the strongest predictor of ever initiating regular smoking. After controlling for other social variables, men with a basic education or less were still 2.5 times more likely to have initiated regular smoking when compared to men with a higher education, while among women an almost 2-fold difference between these groups was observed. Positive associations were also found for unemployment, low occupational status and for the low-income group. However, when other social variables were controlled for, only male unemployment and having a manual occupation among men remained statistically significant predictors of smoking initiation. Among women, those in the mid-income group were significantly less likely to have initiated regular smoking.

View this table:
Table 1

The association of socioeconomic and demographic variables with ever initiating regular smoking in the 25–64 age group in Estonia, 2000–04. Age-standardized prevalence rate (PR) and odds ratios (OR) with 95% confidence intervals (CI)

MenWomen
Model 1Model 2Model 1Model 2
NPR (%)OR95% CIOR95% CINPR (%)OR95% CIOR95% CI
Total180272.9247537.4
Age group
    25–3446769.41.001.0055739.31.001.00
    35–4970774.71.29(0.99–1.68)1.28(0.94–1.73)94142.21.14(0.92–1.41)1.10(0.87–1.40)
    50–6462873.71.23(0.94–1.60)1.14(0.82–1.58)97730.10.65(0.52–0.81)0.66(0.51–0.85)
Marital status
    Married/cohabiting133772.31.001.00163435.71.001.00
    Never married24169.10.79(0.58–1.07)0.61(0.43–0.86)25434.50.89(0.67–1.17)0.91(0.67–1.23)
    Divorced/separated/widowed21483.81.87(1.28–2.73)1.46(0.97–2.20)57846.31.43(1.17–1.75)1.32(1.05–1.65)
Urban/rural residence
    Tallinn45167.21.001.0070340.31.001.00
    Urban82176.41.60(1.24–2.07)1.30(0.96–1.77)119535.20.82(0.68–1.00)0.69(0.55–0.87)
    Rural52772.71.33(1.01–1.75)0.94(0.67–1.33)57038.00.93(0.74–1.17)0.75(0.57–0.99)
Ethnicity
    Estonian127573.01.001.00171837.61.001.00
    Russian42275.01.11(0.86–1.42)1.02(0.76–1.38)61037.70.99(0.82–1.20)0.89(0.71–1.12)
Education
    Higher28751.71.001.0056326.31.001.00
    Secondary114475.02.76(2.11–3.61)1.99(1.43–2.77)158840.21.95(1.57–2.42)1.97(1.52–2.54)
    Basic or less35884.23.61(2.54–5.13)2.49(1.59–3.91)30252.02.13(1.57–2.91)1.85(1.26–2.71)
Economic activity
    Employed/self employed135671.11.001.00168736.01.001.00
    Unemployed18487.12.57(1.66–3.98)1.73(1.06–2.82)15142.31.62(1.16–2.27)1.24(0.85–1.83)
    Economically non-active21070.71.07(0.75–1.52)0.78(0.52–1.18)55841.60.92(0.75–1.13)0.83(0.66–1.06)
Occupation
    Higher non-manual52962.61.001.0072932.01.001.00
    Lower non-manual11976.91.49(0.97–2.30)1.33(0.83–2.14)56138.01.31(1.04–1.65)1.13(0.87–1.49)
    Skilled workers44676.62.09(1.57–2.77)1.70(1.19–2.43)21640.51.52(1.12–2.08)1.23(0.85–1.79)
    Semi-skilled/elementary23479.72.29(1.60–3.29)1.75(1.14–2.70)13544.11.81(1.25–2.64)1.34(0.87–2.09)
Household income
    High54468.11.001.0066237.51.001.00
    Mid67771.61.18(0.92–1.51)0.87(0.65–1.16)95232.10.75(0.61–0.93)0.66(0.52–0.84)
    Low54080.11.90(1.44–2.51)1.19(0.84–1.69)79643.41.26(1.02–1.55)1.05(0.81–1.37)
  • Model 1 – adjusted for age

    Model 2 – adjusted for age and all social variables

Women in Tallinn were more likely to have ever initiated regular smoking compared to the women in smaller towns and rural settlements whereas a reverse pattern was observed among men (although the association among men was not statistically significant). Never married men and women were less likely to have initiated regular smoking (significant only for men), on the other hand, the risk for initiation was higher for divorced, separated or widowed men and women (significant only for women). Women in the 50–64 age group were less likely to have ever initiated regular smoking when compared to younger women.

Figure 1 presents the association between educational level and smoking initiation for the three age groups. An educational gradient for smoking initiation was most noticeable in the 25–34 age group where 83% of men with a basic education or less had ever initiated regular smoking compared with only 34% of men with a higher education; the respective figures among women were 64% and 24%. Among women in the age group 50–64 years there was no statistically significant association between educational level and ever initiating regular smoking. As for other socioeconomic variables, the independent association with smoking initiation was observed for skilled workers in the 35–49 age range, and for the semi-skilled/elementary occupations in the 25–34 age group among men (data not shown).

Figure 1

The age-standardized prevalence rate (%) for ever initiating regular smoking by educational level in three age groups in Estonia, 2000–04

The cessation of smoking showed a different pattern of social variation where the indicators of current social disadvantage were more important in explaining low cessation rates among ever regular smokers (table 2). Lower cessation rates were observed among the unemployed, among those in lower occupational positions and for those in the low-income group. These associations remained after controlling for the other social variables among men but not among women. The strongest association was found with income: 36% of men in the high-income group had quit smoking compared with only 16% of men in the low-income group. At the same time there was no independent association between educational level and smoking cessation when all the age groups were combined. Both occupation and income attenuated significantly this association in the multivariate models for men and women, although among men the effect of occupation was somewhat stronger (data not shown). Compared to Estonians, Russian men were less likely to have quit smoking, but the same association was not found among women. Being married or cohabiting was positively related to an individual's smoking cessation when compared to those who were divorced, separated or widowed (among women only) or who were never married (among men only).

View this table:
Table 2

The association of socioeconomic and demographic variables with quitting smoking among ever regular smokers in the 25–64 age group in Estonia, 2000–04. Age-standardized prevalence rate (PR) and odds ratios (OR) with 95% confidence intervals (CI)

MenWomen
Model 1Model 2Model 1Model 2
PR (%)OR95% CIOR95% CIPR (%)OR95% CIOR95% CI
Total26.532.9
Age group
    25–3422.51.001.0032.51.001.00
    35–4923.01.04(0.75–1.44)0.98(0.68–1.43)28.30.82(0.58–1.18)0.93(0.62–1.40)
    50–6433.71.79(1.29–2.47)1.78(1.21–2.63)38.51.22(0.85–1.77)1.27(0.83–1.95)
Marital status
    Married/cohabiting29.11.001.0036.91.001.00
    Never married13.60.52(0.33–0.84)0.56(0.33–0.95)26.00.69(0.42–1.14)0.86(0.51–1.46)
    Divorced/separated/widowed18.20.58(0.39–0.85)0.70(0.46–1.08)21.30.56(0.40–0.80)0.63(0.43–0.93)
Urban/rural residence
    Tallinn28.21.001.0032.51.001.00
    Urban26.20.87(0.64–1.19)0.93(0.65–1.34)34.81.07(0.77–1.48)1.09(0.75–1.59)
    Rural25.50.85(0.61–1.20)0.98(0.64–1.50)31.20.86(0.58–1.27)0.92(0.58–1.47)
Ethnicity
    Estonian29.01.001.0032.81.001.00
    Russian19.80.60(0.44–0.82)0.58(0.40–0.83)32.10.94(0.67–1.31)1.17(0.79–1.73)
Education
    Higher38.71.001.0040.91.001.00
    Secondary26.40.60(0.41–0.86)0.95(0.61–1.47)32.30.65(0.45–0.95)0.78(0.50–1.23)
    Basic or less18.10.44(0.29–0.68)0.99(0.58–1.71)22.50.51(0.30–0.86)0.63(0.31–1.27)
Economic activity
    Employed/self employed31.41.001.0032.71.001.00
    Unemployed14.50.29(0.17–0.48)0.58(0.33–1.00)12.80.47(0.25–0.88)0.75(0.36–1.54)
    Economically non-active16.30.43(0.28–0.65)0.62(0.38–1.01)41.91.62(1.15–2.29)2.12(1.42–3.15)
Occupation
    Higher non-manual40.01.001.0037.31.001.00
    Lower non-manual24.40.57(0.33–1.00)0.52(0.29–0.95)31.30.72(0.48–1.07)0.80(0.50–1.28)
    Skilled workers28.70.61(0.44–0.85)0.78(0.52–1.17)22.90.49(0.28–0.87)0.52(0.26–1.04)
    Semi-skilled/elementary25.40.54(0.36–0.81)0.79(0.49–1.27)23.10.61(0.33–1.15)0.82(0.39–1.74)
Household income
    High35.71.001.0036.21.001.00
    Mid30.70.78(0.58–1.04)1.06(0.76–1.48)36.91.04(0.73–1.49)1.22(0.82–1.83)
    Low15.90.32(0.23–0.45)0.45(0.29–0.67)26.50.64(0.44–0.91)0.64(0.41–1.02)
  • Model 1 – adjusted for age

    Model 2 – adjusted for age and all social variables

Figure 2 presents the results for quitting smoking among ever regular smokers according to the level of income by age group. The effect of income became stronger and was statistically significant in the age groups above 34 years among men. For the other socioeconomic variables, the independent association with cessation remained for unemployment only in the 35–49 age group and for the lower level non-manual occupations in the 50–64 age group among men and with having a low educational level in the 35–49 age group among women (data not shown).

Figure 2

The age-standardized prevalence rate (%) for quitting smoking among ever regular smokers by income level in three age groups in Estonia, 2000–04

Discussion

The results from the present study showed that educational level was the strongest predictor of ever initiating regular smoking. However, we also found independent, although weaker associations between smoking initiation and indicators of current social disadvantage such as low occupational class and unemployment. Quitting smoking among ever regular smokers was more closely connected with indicators of current material deprivation and economic vulnerability such as having a low income or being unemployed and also with having a low occupational position. Educational level had no direct independent association with smoking cessation. The relative importance of economic factors was larger among men than among women. Smoking was also related to demographic characteristics such as marital status, urban/rural residence and ethnicity.

Potential limitations

The non-response rate was between 33 and 38% in the three surveys. The differences we found when comparing the distribution of the respondents according to their educational level, place of residence and ethnicity with the 2000 census population data were less than six percentage points at most and are not likely to have systematically affected our results. The item non-response for the independent variables was relatively small (3.1% for economic activity was the largest) and therefore unlikely to affect our results. Since 7.7% of quitters had stopped smoking six or less months ago it is possible that some of them had stopped smoking only temporarily. If the relapse rate should be higher for lower socioeconomic groups, we may have overestimated the quitting prevalence among lower socioeconomic groups and thus underestimated the size of socioeconomic differences in smoking cessation.

Socioeconomic variations

An individual's educational level was the strongest predictor of ever initiating regular smoking in Estonia. Among men a strong inverse relationship was found in all age groups, whereas, among women, the reversal was found in the age groups younger than 50 years. This finding leads us to assume that the reversal of the educational gradient in smoking in Estonia took place relatively early, in generations older than 64 years (i.e. born before 1936) among men, and in generations born before 1950 among women. These findings place Estonia in line with the northern European countries, whereas in southern Europe, in the older age groups, the prevalence of ever smoking is greater in higher educated groups, or, the differences have been found to be small.6,,15

The proportion of ever smokers among those aged 25–34 years old in our study mostly reflects the uptake of cigarette consumption in the 1990s. After the collapse of the Soviet Union, the old tobacco control regulations fell into disuse and it was only in 1998 that the first tobacco regulative act came into force that prohibited the advertising of tobacco products.27 The first Estonian Tobacco Act was legally enforced in 2001 prohibiting smoking in public places and in working places, and establishing an age limit for smoking and handling tobacco products.28 In the early 1990s, exploiting the lack of tobacco control policies, transnational tobacco companies rapidly expanded their markets into Eastern Europe by targeting young people and women in particular.29 It is possible that these factors in conjunction with widespread social and economic upheaval contributed to the increasing smoking initiation of younger women from the lower educational groups in Estonia. The same increase was not observed among women in the mid or higher educational groups or among men.

Educational differences in ever initiating regular smoking were only partially explained by adult socioeconomic position as measured by economic activity, occupational class and household income. Smoking is usually initiated during adolescence, which may explain why an individual's educational level is such an important factor; besides, educational level is strongly related to parental socioeconomic position and thereby also to childhood living conditions, which in their own term may affect smoking initiation.30 Previous studies have shown that those who initiate smoking in their early years are more likely to come from social environments that favour smoking (for example the family, peers or neighbourhoods) but that they also tend to be less successful and to have lower self-esteem.31 In contrast, those who stay longer at school may be financially more dependent on their parents, may have a more restrictive social environment as regards smoking, and they may receive better instruction concerning the potential health hazards of smoking—factors that can all be preventive in terms of smoking initiation.

The associations of unemployment and low occupational class with ever initiating regular smoking among men indicates that factors related to adult socioeconomic disadvantage may also be important for smoking uptake, though the possibility cannot be excluded that the causal association here works in both directions.

The positive association between low socioeconomic status and a low cessation prevalence among men accords well with findings from other studies where unemployment, low occupational class32,,33 and poverty34,,35 have all been related to low cessation rates. Several studies have also reported a positive relationship between low educational levels and low cessation rates, but their results rely on the assessment of a single socioeconomic variable.13,15,,36 In this study, the association of education with smoking cessation was explained by a link to other socioeconomic indicators formed later in adult life, i.e. the effect of education may be indirect. Although all socioeconomic groups demonstrate the same degree of intent as regards quitting smoking, lower socioeconomic groups tend not to succeed as often as higher socioeconomic groups.37 Several contributory factors have been related to this inability to quit among lower socioeconomic groups, including having a higher degree of nicotine dependence, low self-efficacy, low social support, exhibiting an external locus of control, as well as financial difficulties.35,37–39 Our results for Estonia suggest that in conditions of economic upheaval, material constraints may become more important determinants of low cessation rates than factors related to education, especially among men who are traditionally considered the families’ breadwinners.

Demographic variations

In the current study we did not find statistically significant differences between Estonians and Russians in ever smoking. On the other hand, Russian men were less likely to quit when compared to Estonian men. This difference in quitting was not explained by the indicators of social disadvantage. Considerably higher excise tax on tobacco products in Estonia when compared to Russia29,,40 may have contributed to the smuggling of cheap cigarettes from Russia into Estonia, particularly in the border regions, which are populated mostly by Russians. This possible access to cheap cigarettes may have contributed to the lower cessation rate among Russian men as the use of the price mechanism is considered one of the most effective tobacco control measures.40 Though tobacco advertizing was prohibited in Russia from 2001, these regulations have remained largely ineffective.10 The Russian population in Estonia mostly watch Russian television programmes and so may have been more greatly affected by tobacco advertizing on Russian television.

Previous studies in the former Soviet republics have found a higher smoking prevalence among divorced, separated or widowed persons.9,,41 Our results show that both a higher initiation rate and a lower cessation rate contribute to this excess. This underlines the fact that stressful life events and social conditions may strongly influence both smoking initiation and smoking continuation. The lower prevalence rate of ever smoking for never married men compared to married men may partly reflect adverse selection into marriage, i.e. smokers are more likely to get married, however, the mechanisms of adverse selection have remained largely unknown.42

Women living in the capital city of Tallinn were more likely to have ever initiated regular smoking when compared to women in smaller cities or rural areas. This urban excess in smoking was found among the middle-aged but not among the youngest age group, which indicates that women's smoking behaviour may be diffusing from the cities to the countryside.

Conclusions

A recent amendment to the Tobacco Act that came into force in June 2005 brought Estonian legislation into line with EU regulations by totally banning smoking in catering establishments.43 While reinforced tobacco control policies will be essential to further reducing the overall smoking prevalence in Estonia, inequalities in smoking might increase if no equity-oriented tobacco control policies are implemented. It is therefore important that any tobacco control policies be tailored to the needs of the socioeconomic groups who lack both the support mechanisms and resources to avoid initiation or to quit smoking. Further, it is also important that future tobacco control measures are implemented that are maximally effective among these groups, such as the provision of free services for smoking cessation. Our results suggest that smoking cessation interventions in Estonia can best be targeted at materially deprived groups, whereas interventions aimed at tackling smoking initiation should primarily focus on adolescents and young adults with a lower education.

Contributors

M. L. outlined the article, did the data analysis, discussed core ideas, drafted the article and prepared the final manuscript. M. T. prepared the data set and commented on the drafts. A. E. K. led the project, discussed core ideas and commented on drafts.

Acknowledgements

This study was conducted within the project ‘Improved monitoring to support policies tackling inequalities in smoking in the European Union’ (project ENSP SPC.2002411) with the contribution of the European Commission grant agreement with the European Network for Smoking Prevention (ENSP). The study has also been supported by the Swedish Foundation for Baltic and East European Studies (project grant ‘Unhealthy societies?—studies of population health determinants in Russia and the new EU member states’). We also want to thank Dr Andrew Stickley for his useful comments on the manuscript and for revising the English.

Ethics Committee approval This study has been approved by the Tallinn Medical Research Ethics Committee (Approval No 509, 28.04.2004).

Conflict of interest: None declared.

Key points

  • Previous studies on social inequalities in smoking in the former Soviet republics have looked at only the prevalence rate of current smoking.

  • This study showed that the social determinants of ever initiating regular smoking differ from those of quitting smoking. Educational level was the strongest predictor for smoking initiation, whereas smoking cessation was more closely related to indicators of current material deprivation and economic vulnerability, but also to ethnic background.

  • In Estonia, the reversal of the educational gradient in smoking among men and women took place relatively early, i.e. in the generations born before 1950.

  • These results suggest that smoking cessation interventions in Estonia can best be targeted at materially deprived groups, whereas interventions aimed at tackling smoking initiation should primarily focus on adolescents and young adults with a lower education.

References

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