Inequalities in the prevalence of smoking in the European Union: comparing education and income

Abstract

Background

The aim of the study was to determine whether education or income was more strongly related to smoking in the European Union at large, and within the individual countries of the EU, at the end of the 1990s.

Methods

We related smoking prevalence to education and income level by analyzing cross-sectional data on a total of 48,694 men and 52,618 women aged 16 and over from 11 countries of the European Union in 1998.

Results

Both education and income were related to smoking within the European Union at large. After adjustment of the other socioeconomic indicator, education remained related to smoking in the EU at large, but income only remained so among men. Educational inequalities were larger than income-related inequalities among younger and middle-aged men and women. Educational inequalities were larger than income-related inequalities among men in all individual countries, and among women in Northern Europe. For women from Southern European countries, the magnitude of education- and income-related inequalities was similar.

Conclusions

Education is a strong predictor of smoking in Europe. Interventions should aim to prevent addiction to smoking among the lower educated, by price policies, school-based programs, and smoking cessation support for young adults.

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.