Socioeconomic Status and Smoking in Canada, 1999-2006 : Has there been any progress on disparities in tobacco use? Jessica Reid, David Hammond, Pete Driezen.

Socioeconomic Status and Socioeconomic Status and Smoking in Canada, 1999-Smoking in Canada, 1999-

20062006::

Has there been any progress on Has there been any progress on disparities in tobacco use?disparities in tobacco use?

Jessica Reid, David Hammond, Pete Jessica Reid, David Hammond, Pete DriezenDriezen

Dept. of Health Studies, University of Dept. of Health Studies, University of WaterlooWaterloo

CPHA Annual ConferenceCPHA Annual ConferenceJune 1-4, 2008, HalifaxJune 1-4, 2008, Halifax

Background: Tobacco Use & Background: Tobacco Use & SESSES

Tobacco use is the leading cause of Tobacco use is the leading cause of preventable death in Canada: 47,000 preventable death in Canada: 47,000 deaths/yrdeaths/yr

Overall smoking prevalence has decreased Overall smoking prevalence has decreased over time; changing demographics of over time; changing demographics of smokerssmokers

Socioeconomic gradient in smoking, withSocioeconomic gradient in smoking, with higher rates in lower SES groupshigher rates in lower SES groups

Tobacco use is a major contributor to overall Tobacco use is a major contributor to overall health inequalitieshealth inequalities

(de Walque, 2004; Giskes et al., 2005, Jarvis & Wardle, 2006; Jha et al., 2006, Makomaski Illing, 2004,Makomaski Illing, 2004, Physicians for a Smoke-free Canada, 2005)

RationaleRationale

Population-level interventions (Population-level interventions (policies policies and programsand programs) may have differential ) may have differential effects by SES ( or )effects by SES ( or )

Research needed to determine effects Research needed to determine effects of recent tobacco control efforts on of recent tobacco control efforts on tobacco-related disparitiestobacco-related disparities

Important to monitor SES trends in Important to monitor SES trends in smoking and quittingsmoking and quitting

ObjectivesObjectives

1.1. To evaluate whether smoking To evaluate whether smoking prevalence and related constructs prevalence and related constructs (quit ratio, consumption, smoking (quit ratio, consumption, smoking frequency, quitting intentions and frequency, quitting intentions and attempts) vary by socioeconomic attempts) vary by socioeconomic status.status.

2.2. To examine whether any identified To examine whether any identified differences have changed over differences have changed over time, from 1999-2006.time, from 1999-2006.

Canadian Tobacco Use Canadian Tobacco Use Monitoring Survey (CTUMS)Monitoring Survey (CTUMS)

Conducted by Statistics CanadaConducted by Statistics Canada

Repeated cross-sectional surveysRepeated cross-sectional surveys

Nationally representative samplesNationally representative samples

Conducted Feb.-Dec. every year, 1999-Conducted Feb.-Dec. every year, 1999-

Telephone interviewsTelephone interviews

Study SampleStudy Sample

Analysis limited to Analysis limited to ≥ ≥ 25 years of age25 years of age

Total n=86 971 (>10 000 per year)Total n=86 971 (>10 000 per year)

~10% from each province~10% from each province

56% female56% female

Mean age: 49.5 yearsMean age: 49.5 years

Education level:Education level: Less than secondary: 23.79%Less than secondary: 23.79% Completed secondary: 38.29% Completed secondary: 38.29% Completed community college: 16.59% Completed community college: 16.59% Completed university: 21.33%Completed university: 21.33%

Measures: Measures: Dependent Dependent VariablesVariables

Total population:Total population:

Smoking prevalenceSmoking prevalence (y/n) (y/n)

Quit ratioQuit ratio (former/ever smokers; continuous) (former/ever smokers; continuous)

Smokers:Smokers:

Smoking frequency Smoking frequency (daily vs. occasional)(daily vs. occasional)

Consumption Consumption – cigarettes per day (continuous– cigarettes per day (continuous))

Seriously considering quitting in next 6 months Seriously considering quitting in next 6 months (y/n)(y/n)

Made Made ≥ ≥ 24-hour quit attempt in past year 24-hour quit attempt in past year (y/n)(y/n)

Measures: Measures: Independent VariablesIndependent Variables

SES: SES: Education Education (4 categories)(4 categories)

Demographics:Demographics: AgeAge (continuous, range: 25-85)(continuous, range: 25-85)

SexSex (categorical: 0 - male, 1 - female)(categorical: 0 - male, 1 - female)

RegionRegion (categorical: Atlantic, Quebec, (categorical: Atlantic, Quebec, Ontario, Western, BC)Ontario, Western, BC)

Consumption Consumption (cigarettes per day (CPD)) (cigarettes per day (CPD)) *quitting analyses only*quitting analyses only

Time Time (survey year)(survey year)

AnalysisAnalysis

Regression modeling (logistic and Regression modeling (logistic and multiple linear) using SAS softwaremultiple linear) using SAS software

Data from individual respondents Data from individual respondents examined in each year for association of examined in each year for association of education and outcomeseducation and outcomes

Summary data set created with Summary data set created with proportion or mean for each outcome by proportion or mean for each outcome by age/sex/region/ education level, used to age/sex/region/ education level, used to test for time trend and interaction of test for time trend and interaction of time*educationtime*education

Results: Results: Smoking prevalenceSmoking prevalence

Overall Smoking Prevalence, 1999-2006

0

5

10

15

20

25

30

1999 2000 2001 2002 2003 2004 2005 2006Year

% C

urr

ent

Sm

oke

rs

Overall

Daily

Occasional

Overall, decrease from 24% (1999) to 18% (2006)Overall, decrease from 24% (1999) to 18% (2006) Significant association with time Significant association with time (p<0.0001)(p<0.0001)

Results: Results: Smoking prevalenceSmoking prevalence

*Includes all current smokers (daily and occasional)

Smoking Prevalence by Education Level, 1999-2006

0

5

10

15

20

25

30

35

1999 2000 2001 2002 2003 2004 2005 2006

Year

% C

urr

en

t S

mo

ke

rs*

<Secondary

Secondary

College

University

Results: Results: Smoking prevalenceSmoking prevalence Less educated more likely to smoke in each yearLess educated more likely to smoke in each year

No interaction of time*education No interaction of time*education (p=0.22)(p=0.22)

Odds of Current Smoking (vs. university)

0 1 2 3 4 5 6

1999

2000

2001

2002

2003

2004

2005

2006

Odds Ratio

College

Secondary<Secondary

Results: Results: Daily/Occasional Daily/Occasional SmokingSmoking

% Smoking Daily by Education Level, 1999-2006

0

20

40

60

80

100

1999 2000 2001 2002 2003 2004 2005 2006Year

% o

f s

mo

ke

rs

<Secondary

Secondary

College

University

Overall, decrease from 85% daily (1999) to 79% (2006)Overall, decrease from 85% daily (1999) to 79% (2006) Significant association with time Significant association with time (p<0.0001)(p<0.0001)

Results: Results: Daily/Occasional Daily/Occasional SmokingSmoking

Among smokers, less educated more likely to smoke Among smokers, less educated more likely to smoke daily in each year; few exceptions daily in each year; few exceptions

No time*education interaction No time*education interaction (p=0.10)(p=0.10)

Odds of Daily Smoking (vs. university)

0 1 2 3 4 5 6 7 8 9

1999

2000

2001

2002

2003

2004

2005

2006

Odds Ratio

CollegeSecondary<Secondary

Results: Results: Consumption (CPD)Consumption (CPD)

Overall, decrease from 16.4 (1999) to 13.6 (2006) Overall, decrease from 16.4 (1999) to 13.6 (2006) CPDCPD

Significant association with time Significant association with time (p<0.0001)(p<0.0001)

Mean cigarettes per day, 1999-2006

0

5

10

15

20

25

1999 2000 2001 2002 2003 2004 2005 2006Year

Cig

aret

tes/

day

(mea

n)

Results: Results: Consumption (CPD)Consumption (CPD)

Mean cigarettes per day, by education, 1999-2006

0

5

10

15

20

25

1999 2000 2001 2002 2003 2004 2005 2006Year

Cig

aret

tes/

day

(mea

n)

<Secondary

Secondary

College

University

Significant effect of education Significant effect of education (p<0.0001)(p<0.0001)

No time*education interaction No time*education interaction (p=0.73)(p=0.73)

Results: Results: Quit IntentionsQuit Intentions

No significant differences by educationNo significant differences by education Exception: 2001, uni. vs. <sec. OR=1.98 (1.19-3.31)Exception: 2001, uni. vs. <sec. OR=1.98 (1.19-3.31)

Significant association with time Significant association with time (p<0.0001)(p<0.0001) No time*education interaction No time*education interaction (p=0.37)(p=0.37)

“Seriously considering quitting in next 6 months”

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006Year

% o

f s

mo

ke

rs

<Secondary

Secondary

College

University

Results: Results: Quit AttemptsQuit Attempts

No significant differences by educationNo significant differences by education Exception: 2005, uni. vs. <sec. OR=0.52 (0.29-0.92)Exception: 2005, uni. vs. <sec. OR=0.52 (0.29-0.92)

No significant association with time No significant association with time (p=0.88)(p=0.88) Significant time*education interaction Significant time*education interaction (p=0.02)(p=0.02)

Made a quit attempt lasting ≥24h in past year

0

10

20

30

40

50

60

2000 2001 2002 2003 2004 2005 2006Year

% o

f sm

oke

rs <Secondary

Secondary

College

University

Results: Results: Quit ratiosQuit ratiosQuit Ratio by Education Level, 1999-2006

00.10.20.30.40.50.60.70.8

1999 2000 2001 2002 2003 2004 2005 2006Year

Qu

it R

atio

(f

orm

er/e

ver

smo

kers

)

<Secondary

Secondary

College

University

University grads significantly higher than othersUniversity grads significantly higher than others (except college in 2006, <secondary in 2000, 2003, 2004)(except college in 2006, <secondary in 2000, 2003, 2004)

Significant association with time Significant association with time (p<0.0001)(p<0.0001)

No time*education interaction No time*education interaction (p=0.33)(p=0.33)

Summary and ConclusionsSummary and Conclusions Considerable SES disparities in smoking exist Considerable SES disparities in smoking exist

in Canada, for prevalence and consumptionin Canada, for prevalence and consumption

Good news: such disparities have not widened Good news: such disparities have not widened considerably, but . . .considerably, but . . .

Bad news: they have not decreased eitherBad news: they have not decreased either

Good news: lower SES groups are not less Good news: lower SES groups are not less likely to intend to quit or attempt to quit, but . likely to intend to quit or attempt to quit, but . . .. .

whether/how this may translate into whether/how this may translate into cessation is unknowncessation is unknown

Recent policies do not seem to be worsening Recent policies do not seem to be worsening disparities, but are unlikely to reduce themdisparities, but are unlikely to reduce them

AcknowledgementsAcknowledgements Data: This study analysed public-use data Data: This study analysed public-use data

collected by Statistics Canada. Tcollected by Statistics Canada. The results he results and views expressed in this paper are those and views expressed in this paper are those of the authors and are not those of Statistics of the authors and are not those of Statistics Canada.Canada.

Student funding: The first author is supported Student funding: The first author is supported by a CIHR Strategic Training Program in by a CIHR Strategic Training Program in Tobacco Research (STPTR) Fellowship and an Tobacco Research (STPTR) Fellowship and an Ontario Graduate Scholarship.Ontario Graduate Scholarship.

Conference attendance: CPHA Population and Conference attendance: CPHA Population and Public Health Student Award (Master’s Level)Public Health Student Award (Master’s Level)

Thank you.Thank you.

Questions?Questions?