Short reportSmoking initiation, continuation and prevalence in deprived urban areas compared to non-deprived urban areas in The Netherlands
Introduction
Even though the prevalence of smoking has been declining for several decades (Giskes et al., 2005), smoking remains the most important source of mortality and disease burden worldwide (Rehm, Taylor, & Room, 2006). A major part of the difference in mortality between lower and higher socio-economic status (SES) groups is due to differences in smoking (Jha et al., 2006). In 2010, 34% of Dutch males with a lower educational level were smokers compared to 22% of males with a higher educational level. Females showed similar differences: 33% and 18% respectively (Zeegers, Blokstra, & Zantinge, 2011).
Along with individual SES, socio-economic and physical features of the neighbourhood are also associated with tobacco use. Previous studies found residents of deprived areas to be more likely to smoke than people living in more affluent areas (Chuang, Cubbin, Ahn, & Winkleby, 2005; Diez Roux, Merkin, Hannan, Jacobs, & Kiefe, 2003; Duncan, Jones, & Moon, 1999; Ellaway & Macintyre, 2009; Giskes, van Lenthe, Turrell, Brug, & Mackenbach, 2006; Kaestle & Wiles, 2010; Kleinschmidt, Hills, & Elliott, 1995; Ohlander, Vikstrom, Lindstrom, & Sundquist, 2006; Reijneveld, 2002; Ross, 2000; Shohaimi et al., 2003; Stead, MacAskill, MacKintosh, Reece, & Eadie, 2001; Tseng, Yeatts, Millikan, & Newman, 2001; van Lenthe & Mackenbach, 2006). Most studies used current smoking as the outcome variable. Results consistently showed that smokers are more likely to live in deprived areas (Diez Roux et al., 2003; Duncan et al., 1999; Ellaway & Macintyre, 2009; Kaestle & Wiles, 2010; Kleinschmidt et al., 1995; Reijneveld, 2002; Ross, 2000; Shohaimi et al., 2003; van Lenthe & Mackenbach, 2006). Most studies showed that effects of the area socio-economic environment on smoking could not be attributed solely to residents' individual characteristics like SES (Chaix, Guilbert, & Chauvin, 2004; Chuang et al., 2005; Diez Roux et al., 2003; Duncan et al., 1999; Ellaway & Macintyre, 2009; Giskes et al., 2006; Kleinschmidt et al., 1995; Reijneveld, 2002; Ross, 2000; Shohaimi et al., 2003; van Lenthe & Mackenbach, 2006).
To effectively support policymakers in tackling smoking in deprived areas, more information is needed about why smoking rates are higher in these areas than in other, non-deprived, areas. A higher smoking prevalence in deprived areas could be attributable to residents being more likely to start smoking and/or less likely to quit smoking. Making a distinction between smoking initiation and cessation will be relevant to determining the focus of policy and interventions. Furthermore, identifying subpopulations in which differences between deprived and non-deprived areas are particularly large might help to target groups in deprived areas.
Few studies have separated the concept of smoking initiation from smoking cessation. According to Shohaimi and colleagues (Shohaimi et al., 2003), residents of more deprived areas in the United Kingdom were less likely to report having never smoked, while Tseng et al. (Tseng et al., 2001) found no association between area-level socio-economic characteristics and ever-smoking. In the latter study, continuation of smoking among ever-smokers was more common in areas with a greater number of less-educated and unemployed residents. This result is in line with a study by Giskes and colleagues (Giskes et al., 2006), which showed that residents of more deprived areas in the Dutch city of Eindhoven were less likely to quit smoking.
Few studies have looked into possible differences between population subgroups. Previous studies have found larger area-level differences in smoking among individuals in low SES groups (Ohlander et al., 2006; van Lenthe & Mackenbach, 2006). Öhlander et al. found that the association between area deprivation and smoking was stronger in younger adults (Ohlander et al., 2006). Results were ambiguous when stratified by gender (Cohen, Sonderman, Mumma, Signorello, & Blot, 2011; Ellaway & Macintyre, 2009; Ohlander et al., 2006; Ross, 2000; Shohaimi et al., 2003). Öhlander et al. (Ohlander et al., 2006) and Cohen and colleagues (Cohen et al., 2011) suggested that differences are clearest among women, while Ross (Ross, 2000) found stronger associations in men.
The aim of this study was to determine the relationship between area deprivation and current smoking, smoking initiation (i.e. ever-smoking) and smoking continuation (i.e. not quitting) in urban areas. We also aimed to identify subpopulations (defined by age, gender and education) in which area-level differences in smoking are most profound. We used an extensive national survey that was large enough to distinguish between different smoking outcomes and between various subpopulations.
Section snippets
Study population
Variables were measured at individual and area levels. Individual level data of 20,603 Dutch adults age 18 and over were derived from the 2003–2009 national Integrated Survey on Living Conditions (POLS). The POLS is an extended interview questionnaire conducted annually among a population-based sample of the Dutch population. According the Medical Ethics Committee of the Academic Medical Centre Amsterdam, an official ethical approval is not required. The manuscript is entirely based on
Results
Residents of deprived areas differed from residents of non-deprived urban areas on several characteristics. Table 1 shows that deprived areas had a larger proportion of residents from non-Western ethic minorities and that educational level and household income were lower.
In Table 2, differences between deprived and non-deprived areas are also presented for smoking outcome variables. In the total population as well as in all the separate subgroups, there were more current smokers in deprived
Key findings
Smoking initiation, continuation and current smoking were more prevalent in deprived areas. Associations between area deprivation and current smoking and smoking continuation were accounted for by individual characteristics. Significant associations were found between area deprivation and smoking initiation for younger generations and more highly educated respondents. Therefore, the higher prevalence of smoking in deprived areas seems mainly attributable to smoking initiation rather than to
Acknowledgements
We gratefully acknowledge Statistics Netherlands for preparing micro-level data of the POLS survey, and providing access to these data.
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