Inequalities in the prevalence of smoking in the European Union: comparing education and income
Introduction
Several studies have demonstrated that the prevalence of smoking in populations of developed countries is related to socioeconomic status [1], [2], [3], [4], [5], [6]. Smoking is an important risk factor for some diseases and causes of death and it has been shown that a substantial part of socioeconomic inequalities in morbidity and mortality can be linked to smoking [7], [8], [9]. Studies that describe socioeconomic inequalities in smoking therefore contribute to an understanding of the determinants of smoking and, indirectly, to determinants of health inequalities. Furthermore, they serve to identify the subgroups of the population who need most attention in policies aiming to reduce smoking.
In most research in European countries, socioeconomic inequalities in smoking have been described according to level of education. Smoking is often initiated during adolescence, a time in which school environment plays an important role in daily life. School performance [10], [11] and peer pressure [12], [13], [14] are related to smoking initiation, and are likely to be related to lower educational level. However, after leaving school and moving into the workforce, other socioeconomic determinants, such as income, may have a stronger influence on smoking initiation and continuation. After completion of education, its stability in life thereafter fails to reflect changes in personal circumstances that may be relevant to the initiation and continuation of smoking behavior. Income is an indicator that more accurately than education reflects an adult's current social position. Some researchers have indeed shown that income is also related to health behaviors, including smoking, after adjustment for education [15], [16], [17], although it has also been reported otherwise [18]. Nevertheless, to our knowledge, a direct comparison of educational and income inequalities in smoking has not been reported.
The effects of education and income on smoking can be expected to differ between countries because the diffusion of smoking within the national population differs between European countries [3], [4]. Toward the later stages of the diffusion of the smoking epidemic, when the overall prevalence of smoking is declining, smoking is more and more associated with lower socioeconomic status [1], [3], [19]. At these stages, smoking as a habit may perhaps be more related to material circumstances and deprivation. Smoking in Britain for instance is concentrated in the lower income groups [20] and smoking serves to cope with the stress of living in disadvantaged circumstances [21]. In the earlier stages of the epidemic, as smoking is not as widespread in the population, smoking may be more strongly related to education, and smoking as a habit may signal innovation and emancipation among higher educated men and women. This means that results of studies on data from the US, or Northern European countries may not be generalized to express the situation in central and southern parts of Europe.
The aim of this study is to compare educational and income inequalities in smoking in the European Union, including countries from northern, central and southern parts of Europe, at the end of the 1990s. We compare these inequalities for the pooled population of 11 countries of the European Union, and for each of these countries separately. Our specific interest was in determining whether education or income was more strongly related to smoking, and to assess whether each has an independent effect.
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Data and methods
Data from the fifth wave (1998) of the European Community Household Survey (ECHP) were analyzed. The ECHP is a social survey designed for the member states of the European Union, which uses a uniform random sampling design and common blueprint questionnaires for use in all the countries included. For all countries, the target population of the panel survey is the national household population. Data are collected by national statistical institutes or research centers. Data checks, imputation,
Results
Smoking prevalence rates and relative inequalities according to education are given in Table 3. An inverse educational gradient was found among men of all ages combined, with the prevalence of smoking being higher among the lower educated compared to the higher educated (OR = 1.73; CI = 1.66–1.81). Relative inequalities in smoking could be demonstrated with statistical significance for all age groups, with the ages 75+ years as the only exception. The educational inequalities were largest in
Discussion
Both education and income were related to smoking in the European Union. Both remained related to smoking after adjustment for the other socioeconomic indicator. Education remained related both among men and among women of the EU at large, whereas income only remained related to smoking among men. The independent effect of education was larger as compared to income, among men up to the ages 54 years, and among women up to the ages 44 years. Inequalities in smoking related to education were
Acknowledgments
Financial support for this study comes from the project “Socio-Economic determinants of Healthy Ageing” (SEdHA), which is subsidised as part of the Fifth Framework Programme on ‘Quality of Life and Management of Living Resources' of the European Commission. This paper is also supported by the project “Tackling socioeconomic inequalities smoking in Europe” which is financed by the European Commission (SANCO) through the European Network on Smoking Prevention (ENSP).
References (32)
Socio-economic differences in smoking: Dutch adolescents' beliefs and behaviour
Soc. Sci. Med.
(1995)Smoking prevalence among women in the European Community 1950–1990
Soc. Sci. Med.
(1996)- et al.
Socioeconomic inequalities in lung cancer mortality in 10 European populations
Eur. J. Cancer
(2004) - et al.
Cultural, material and psychosocial correlates of the socio-economic gradient in smoking behaviour in adults
Prev. Med.
(1997) - et al.
Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe
Soc. Sci. Med.
(1997) - et al.
Trends in cigarette smoking in the United States; educational differences are increasing
JAMA
(1989) - et al.
Educational differences in smoking: international comparison
BMJ
(2000) - et al.
Ten-year trends in smoking behaviour among adults in southern Germany
Int. J. Tuberc. Lung Dis.
(2002) - et al.
Prevalence of cigarette smoking by birth cohort among males and females in Spain, 1910–1990
Eur. J. Cancer Prev.
(2003) - et al.
Health inequalities: decennial supplement
(1997)