International Differences in Mortality at Older Ages Dimensions and Sources (2010) / Chapter Skim
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5 Divergent Patterns of Smoking Across High-Income Nations--Fred Pampel
5 Divergent Patterns of Smoking Across High-Income Nations--Fred Pampel
Pages 132-163
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From page 132... ...
Policies now focus on more stringent restrictions, such as bans on indoor smoking in bars, restaurants, and workplaces; steep increases in tobacco taxes and cigarette prices; and strict enforcement of limits on sales to minors and tobacco company promotions (Davis et al., 2007; Eriksen and Cerak, 2008)
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From page 133... ...
Even among the most educated, the low rates still translate into millions of smokers. Among the less educated, the problem is considerably worse and has led to government efforts in the United States to focus on eliminating SES disparities in smoking (Fagan et al., 2004)
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From page 134... ...
But for insight into the national differences, other factors relating to government policies, social patterns of smoking, beliefs, and the timing of adoption need to be considered. The next sections review explanations of the cross-national patterns of smoking and then examine variation in smoking prevalence among high-income nations.
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From page 135... ...
Furthermore, nations that began the epidemic earlier should show stronger SES disparities in smoking among men, as the diffusion process has had more time for low-SES groups to adopt smoking and high-SES groups to stop smoking. Because of the female lag in adoption, however, the patterns may be less clear among women.
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From page 136... ...
However, as national income further increases, another mechanism tends to lower smoking, particularly among high-SES groups. The growing longevity that accompanies economic growth makes the health costs of smoking greater and more obvious, and the costs come to outweigh any benefits.
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From page 137... ...
To maximize the number of countries with data, the analysis examines male and female smoking prevalence for the years from 1950 to 1995. Because the harm of smoking accumulates over several decades, data ending in 1995 can still help to explain current levels of mortality (and can be supplemented later with more recent figures available from other sources)
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From page 138... ...
It is notable that, when percentages are averaged across all years, the United States has lower smoking than nearly all European nations. The patterns in the next columns, for female smoking, show quite different orderings.
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From page 139... ...
. SOURCE: Author's calculations from International Smoking Statistics and World Health Organization mortality database.
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From page 140... ...
The same correlations with Japan omitted equal .506 and .398. For women, who are not affected strongly by outliers, the correlations of the female lung cancer rate with female prevalence and cigarette consumption equal .719 and .541.
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From page 141... ...
Cigarette Consumption 0.365 0.398 0.541* Female Lung Male Lung Cancer Rate Cancer Rate Level and Change All No All No Multivariate Standardized Nations Japan Nations Japan All Nations Male Prevalence 0.269 0.495*
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From page 142... ...
Although none of the measures of smoking prove ideal in predicting subsequent mortality, the prevalence measures work well and distinguish between male and female smoking. The next step is to explain national patterns in these measures.
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From page 143... ...
For men, nations with high GDP and cigarette consumption early on have low smoking later on; for women, whose smoking follows that of men after a lag, high GDP and cigarette consumption in the past lead later to high smoking among women and gender convergence in smoking. Conversely, low GDP and cigarette consumption in the past and a late start to the epidemic lead to high male smoking and low female smoking.
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From page 144... ...
SOURCES OF NATIONAL DIFFERENCES: INDIVIDUAL DATA Eurobarometer 2006 Even were updated figures on men and women for more recent years available from International Smoking Statistics, other sources of data that distinguish smoking by SES are needed to fully test the arguments. The various theories of national differences make competing predictions about SES disparities in smoking as well as levels of smoking.
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From page 145... ...
Although specifying different causes of low rates of smoking, the two groups of arguments predict similarly low rates of smoking among the same set of mostly northern nations with a long history of smoking and strong antitobacco policies. However, the tax and regulation arguments differ from the diffusion arguments in regard to SES disparities in smoking.
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From page 146... ...
Hand-rolled cigarettes, even if smoked less often than readily available manufactured cigarettes, lack filters that reduce the harm of tobacco smoke. Occasional smokers have lower health risks than regular smokers, but experts say that any level of smoking is dangerous.
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From page 147... ...
Thus, younger age groups entering adulthood at later stages of diffusion show stronger SES disparities, whereas older age groups entering adulthood many decades ago during earlier stages of diffusion show weaker SES disparities. Aggregate Influences Table 5-6 examines a different set of determinants.
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From page 148... ...
INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES TABLE 5-5 Unstandardized Coefficients and t Statistics from Multilevel Logistic Regression of Current Smoking on Individual Predictors Males Females b Variance b Variance Predictors t Components t Components Age 0.107*
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From page 149... ...
DIVERGENT PATTERNS OF SMOKING ACROSS HIGH-INCOME NATIONS Descriptive Statistics Females Males Mean Mean All Min All Max 45.39 45.09 26 64 2181.20 2152.31 6776 4096 1.89 1.89 1 3 0.65 0.65 0 1 0.99 0.99 0 1 6.21 5.93 0 10 0.99 0.93 0 1 5.93 5.53 0 12 0.69 0.67 0 1
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From page 150... ...
0.014 0.000 0.039 t 1.980 0.954 0.039 0.260 Ex-Communist Nations (=1) b 0.041 –0.012 –0.008 –0.153 t 0.700 –0.703 –0.933 –0.974 Tobacco Control Scalea b –0.115*
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From page 151... ...
DIVERGENT PATTERNS OF SMOKING ACROSS HIGH-INCOME NATIONS Level-1 Female Intercept and Slopes as Outcomes Intercept Education Occupation Goods Owned –0.001 –0.044*
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From page 152... ...
(2006) report figures on male and female prevalence in the early 2000s from the Tobacco Control Country Profiles that 6I assign the same values for the aggregate variables to East and West Germany, Great Britain and Northern Ireland, and the Cyprus Republic and Cypriot Turkish Community.
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From page 153... ...
Although from the same data set, ever smoking differs from the outcome variable of current smoking and reduces definitional overlap. With either source of prevalence data, the ratio of male to female smoking is an obvious and trivial predic tor of the likelihood of smoking among men or women, but it may indicate less obviously how the stage of cigarette diffusion moderates the influence of SES on individual smoking.
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From page 154... ...
The truncated sample makes these results only suggestive, but it could be that beliefs change with the stage of the epidemic. DISCUSSION The analyses presented in this study, although limited methodologically in many ways, tend to tell a consistent story about national variation in levels, trends, and SES differences of smoking: cigarette smoking is initially adopted by high-SES men, the habit diffuses first to men in other SES groups and later to high-SES women, high-SES men then reject smoking, male and female smoking rates converge, and SES disparities in smoking grow (Mackenbach, 2006)
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From page 155... ...
Among the lowest were Austria, Germany, Italy, Portugal, and Spain. What causes conergence in male and female smoking rates in nations like the United States and Sweden but substantially lower smoking among women than men in Southern Europe?
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From page 156... ...
Although Italy is an exception, the former group has consistently lower smoking rates among men than the latter group. However, the Eurobarometer data show little association between restrictive policies and female smoking prevalence or SES disparities in smoking.
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From page 157... ...
To qualify claims on behalf of the diffusion argument, the evidence is more illustrative than authoritative. The measures of smoking across nations show inconsistencies, the measures of diffusion are imprecise, and the measures of tobacco control policies cover only the more recent years.
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From page 158... ...
Without following individuals over time, consecutive cross-sectional data that cover a decade or more and have comparable measures across a large number of nations can better establish causal relations by comparing changes over time as well as differences across nations in policies, diffusion stage, and SES disparities. If the data also identify areas within nations, particularly those with different linguistic, religious, and ethnic compositions, it might give further insight into the social dynamics of diffusion.
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From page 159... ...
. The hitchhiker's guide to tobacco control: A global assessment of harms, remedies, and controversies.
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From page 160... ...
. Tobacco control policies and smoking in a population of low education women, 1992-2002.
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From page 161... ...
. Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries.
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From page 162... ...
. Other control variables include age or years since birth treated as a quadratic term to reflect the increase and decrease in smoking prevalence 9LetD equal the dummy variable for completed education and E equal the age of completing education as a centered variable with a mean of zero.
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From page 163... ...
DIVERGENT PATTERNS OF SMOKING ACROSS HIGH-INCOME NATIONS over the life course. Dummy variables code women as 1, and code married, remarried, or currently living with a partner as 1.
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