Elsevier

Social Science & Medicine

Volume 66, Issue 3, February 2008, Pages 609-619
Social Science & Medicine

Marital status and smoking in Korea: The influence of gender and age

https://doi.org/10.1016/j.socscimed.2007.10.005Get rights and content

Abstract

Few studies have examined the influence of marriage on health-related behavior in Asian populations. The present study examined the effect of marital status on smoking in Korea.

Data from two rounds of a nationally representative survey (1999 and 2003) were analyzed (57,246 women and 52,769 men). Marital status-specific prevalence ratios for smoking were estimated using log binomial regression after adjusting for age, survey year, occupation and education level. Smoking prevalence declined with age for men, but rose for women. Smoking rates were higher for unmarried men and women compared to their married counterparts. However, the gap in smoking rates between unmarried and married women (especially younger women <45 years) was much greater than the gap between unmarried and married men. The study found that marital status had a stronger protective influence on smoking in women than men, which contrasts with the gender pattern reported previously in western studies. The findings suggest the influence of a culture which discourages married women from smoking, and “liberates” divorced women from cultural sanctions against smoking in marriage.

Introduction

Cigarette smoking is a major contributor to mortality and morbidity in Korea. In the late 1980s more than 70% of adult Korean men were smokers, and although that proportion has recently decreased, a 2005 national survey showed that over 50% still smoked. Smoking in Korean women is much less common, and over a similar time period the proportion of women who smoke decreased from 12.6% to 6% (Department of Health and Welfare, 2007). Socioeconomic differentials in smoking also favored those with higher education, higher incomes and more prestigious occupations, for both genders in Korea (Cho, Khang, & Yun, 2006; Cho, Song, Davey Smith, & Ebrahim, 2004; Khang & Cho, 2006). A 1999 study found that the smoking-attributable burden of premature death was 57.7% in males and 11.4% in females (Ha et al., 2003) and that smoking accounted for approximately 30% of all causes of death, as well as 37% and 27% of cancer and cardiovascular death in Korean men, respectively (Jee et al., 2005). Moreover, smoking was the most important contributor to the socioeconomic mortality disparity in Korea, representing more than 30% of the socioeconomic differences in all-cause mortality (Khang, Lynch, Jung-Choi, & Cho, in press). These findings indicate that tobacco control needs to be a major public health priority in Korea.

Studies have consistently shown that married persons are healthier in terms of morbidity (Schoenbom, 2004) and mortality compared to their unmarried (never-married, divorced or widowed) counterparts. The mortality rate for the unmarried is generally higher than for the married among both the middle-aged and elderly (Ben-Shlomo, Davey Smith, Shipley, & Marmot, 1993; Ebrahim, Wannamethee, McCallum, Walker, & Shaper, 1995; Hu & Goldman, 1990; Johnson, Backlund, Sorlie, & Loveless, 2000; Kaplan & Kronick, 2006; Lund et al., 2002; Manzoli, Villari, Pirone, & Boccia, 2007; Rosengren, Wedel, & Wilhelmsen, 1989).

The two competing explanations for better health in the married population have been referred to as ‘marriage protection’ and ‘marriage selection’ (Schoenbom, 2004). Marriage protection posits that married people have more advantages with respect to economic resources, as well as receipt of social and psychological support (e.g., to avoid smoking, alcohol and drug abuse). For example, with respect to health-related behavior, US cohort studies found that becoming divorced or widowed was associated with decreased vegetable intake and increased alcohol consumption in widowed men (Eng, Kawachi, Fitzmaurice, & Rimm, 2005), as well as an increased risk of relapsing/starting smoking in women (Lee et al., 2005). Moreover, marital disruption is itself associated with greater stress and bereavement (in the case of widowhood). By contrast, the marriage selection theory suggests that healthier people get married and stay married, whereas less healthy people either do not marry or are more likely to become divorced or widowed.

The meanings of the words like “smoking” and “marriage” may vary with societies with different cultural background. However, in general, married persons have a lower smoking rate (Cox, Feng, Canar, & Ford, 2005; King, Grizeau, Bendel, Dressen, & Delaronde, 1998) and a higher smoking cessation rate, most likely reflecting the effects of social influence within marriage (Broms, Silventoinen, Lahelma, Koskenvuo, & Kaprio, 2004; Chandola, Head, & Bartley, 2004; Rice et al., 1996; van Loon, Tijhuis, Surtees, & Ormel, 2005). In studies conducted in the west, wives’ influence on their husband's behaviors (e.g., encouraging smoking cessation) is thought to be stronger than the reverse (i.e. women “nag” men more than the other way round) (Nystadt, 2006; Rhakonen, Laaksonen, & Karvonen, 2005), whereas studies conducted in Asia have not reported consistent findings. For example, marital status was not related to cigarette smoking in China (Yu et al., 2000), and it was higher only in the divorced population (not the widowed or never-married) compared to the married population in Japan (Fukuda, Nakamura, & Takano, 2005). A Saudi Arabian study found that smoking was more prevalent in the married compared to the unmarried (Jarallah, Al-Rubeaan, Al-Nuaim, Al-Ruhaily, & Kalantan, 1999).

Smoking behavior, especially in women, is heavily influenced by gender roles and social norms. Graham reported that women's smoking was linked to the burden of child caring responsibilities in single female-headed households (Graham, 1994). Most Korean children are cared for by their mothers, whether in a married or a divorced/widowhood situation. Women's relative economic and political status is lower in Korea than in other developed countries.

Korea experienced rapid economic growth beginning in the 1960s with per capita gross national income (GNI) of 254 USD in 1970 rising to 16,251 USD by 2005, and changed from an agricultural society with only 28% of the population living in urban area in 1960 to an industrialized society with 81.5% living in urban area by 2005. With rapid industrialization and urbanization, average years of educational attainment for women rose from 6.6 years in 1980 to 10.5 years by 2005, though it was still lower than men's average educational attainment (12.0 years in 2005) (Korean National Statistical Office, 2007) According to the United Nations Gender Empowerment Measure which monitors women's autonomy along economic, educational, and political dimensions, Korea ranked 53rd out of 75 countries, and was far behind most developed countries (UNDP, 2006). In addition, in countries where women's smoking is socially discouraged and restricted through social and/or religious norms (e.g., some Asian countries such as China, South Korea and some Muslim countries) (Khang & Cho, 2006; Rani, Bonu, Jha, Nguyen, & Jamjoum, 2003; Yang et al., 1999) smoking by women, especially married women, can be restricted by social pressure applied from both inside and outside the family. In such cases, becoming divorced or widowed may release women from the force of sanctions and expectations.

Smoking rates in women have been positively related with age in some Asian countries (Khang & Cho, 2006; Rani et al., 2003; Yang et al., 1999), which differs from the Western context where women's rates of smoking has risen with each successive generation (Graham, 1996). It may be that in Korea, older women may find it easier to smoke due to less social pressure on this age group stemming from the general respect shown for the elderly in Confucian traditions.

Considering women's relatively lower socioeconomic position (SEP) to men as well as the influence of culture as a determinant of health behaviors, we hypothesized that the relationship between marital status and smoking would be different in Korea compared to what has been reported from Western countries. Both the meaning of “marital status” as well as behaviors such as smoking may vary according to the cultural context. Variations in cultural context therefore complicate any attempts to carry out cross-national comparative research. Nonetheless, we are unaware of any previous studies specifically focusing on the effect of marital status on smoking rate in Asian countries.

Section snippets

Data sources and study subjects

Data were derived from the social statistics survey (SSS) conducted by the Korea National Statistical Office. These data are generated from face-to-face interviews conducted nationally from randomly selected households. Sections regarding health are included on the survey once every 3–4 years. Non-response rates for these surveys tend to be very low (1.7% in 1999 and 3.9% in 2003). The publicly available SSS data from the 1999 and 2003 surveys which included information on smoking were combined

General description

The number of study subjects was 110,015, of whom 52% were women. Among women, 77% were married, while 7.3%, 13.5% and 2.4% were never-married, widowed and divorced, respectively. Among men, 80% were married, while 15.4%, 1.7% and 2.3% were never-married, widowed and divorced, respectively (Table 1). The composition of marital status according to age group differed between genders. The never-married category was more prevalent among men less than 45 years old, while the widowed was more common

Smoking and SEP

Smoking was found to be inversely related to the education level, and was higher in manual workers for both genders. These findings are consistent with previously reported Korean studies (Cho, Khang, & Yun (2006), Cho, Song, Davey Smith, & Ebrahim (2004); Khang & Cho, 2006).

Smoking rates for the married versus unmarried

The present study found that the smoking rate was higher in unmarried compared to married people. This finding is consistent with those of many Western studies of both men and women (Eng et al., 2005; Lee et al., 2005;

Limitations

The present study was cross-sectional in design, meaning that a definite causal relationship between marital status and smoking could not be established. Selection is also possible. The divorce rate for smokers is twice that for non-smokers (Fu & Goldman, 2000), and men who continue smoking have a lower probability of getting married (Broms et al., 2004). But, because the effect of marital status on smoking is stronger in men than women (Fu & Goldman, 2000), this cannot explain the

Conclusions

In Korean women, while there was an invariably protective relationship between marriage and smoking at all ages, this was not true for Korean men. The magnitude of the association between marital status and smoking as measured by PRs was greater for Korean women than men. These data suggest that divorce or widowhood have different meanings for women, i.e., liberation from social constraints on smoking in addition to the protective effect of marriage. Stronger effect of marital status on the

Acknowledgment

The authors gratefully acknowledge Dr. Sung-Cheol Yun (Division of Epidemiology and Biostatistics, Clinical Research Center, Asan Medical Center) for statistical support.

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