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Marital status and smoking in Korea: The influence of gender and age
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Social Science & Medicine 66 (2008) 609–619 www.elsevier.com/locate/socscimed
Marital status and smoking in Korea: The influence of gender and age Hong-Jun Choa,, Young-Ho Khangb, Hee-Jin Junc, Ichiro Kawachid a
Department of Family Medicine, University of Ulsan, College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul 138-736, Republic of Korea b Department of Preventive Medicine, University of Ulsan, College of Medicine, Seoul, Republic of Korea c Channing Laboratory, Brigham & Women’s Hospital/Harvard Medical School, USA d Department of Society, Human Development and Health, Harvard School of Public Health, USA Available online 8 November 2007
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 o45 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. r 2007 Elsevier Ltd. All rights reserved. Keywords: Korea; Smoking; Marital status; Gender; Age
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 Corresponding author. Tel.: +82 2 3010 3812; fax: +82 2 3010 3815. E-mail addresses: [email protected] (H.-J. Cho), [email protected] (Y.-H. Khang), [email protected] (H.-J. Jun), [email protected] (I. Kawachi).
0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2007.10.005
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;
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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 nevermarried) 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
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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. Methods 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. Nonresponse 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 to derive stable smoking rates for women (o5%). Data included 110,015 subjects (57,246 women and 52,769 men) aged from 25 to 74 years.
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Marital status and socioeconomic variables Marital status was categorized as married, nevermarried, widowed or divorced. Education level was classified as elementary school or less, middle school, high school or college or higher. Occupations were based on the South Korean standard for classifying occupations, derived from the International Standard Classification of Occupation (ISCO) of the ILO. Occupations were classified as non-manual or manual. Non-manual occupations included managers, professionals, technicians and clerks, while manual occupations included service and sales workers, agricultural and fishery workers, crafts and related trade workers, plant and machine operators and assemblers, and elementary occupations. Those who were not in the labor market (unemployed, retired, students and homemakers) were categorized as other. Smoking variables The outcome variable for the study was current cigarette smoking measured by the question ‘‘Do you smoke tobacco now?’’ (‘‘Yes, I smoke,’’ ‘‘I smoked before but I quit smoking,’’ or ‘‘I never smoked’’). Respondents who answered, ‘‘Yes, I smoke’’, were categorized as current smokers. Statistical analysis Analyses were performed separately for men and women. Marital status-specific crude smoking rates by age were calculated. These crude smoking rates were directly age standardized to survey year and 5-year age groups, with age distribution of the total sample as the standard, producing survey year- and age-adjusted smoking rates. Confidence intervals (CI) of these adjusted smoking rates were estimated. Estimated prevalence ratios (PRs) (95% CI) were used, instead of odds ratios because the prevalence of the outcome (smoking) violates the ‘‘rare outcome assumption’’ of logistic models in the case of South Korean men. Log binomial regression with PROC GLIMMIX analysis was performed using SAS statistical software. To control the effect of survey year and age, survey year- and age- (within age group)-adjusted PRs according to marital status were calculated. Marital status-specific PRs adjusting for SEPs were also estimated with adjustments for education and occupational class.
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Results 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 nevermarried, 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 among women older than 45 years (Table 2). The average smoking rate for women was 3.7%, and this increased with age, while, the average smoking rate for men was 62.7%, and decreased with age (Table 1). The age-adjusted smoking rate for the unmarried was higher than for the married in both genders, with the highest rate observed in the divorced. Smoking was more prevalent among both men and women with lower SEP (Table 1). There was a significant interaction between gender and marital status in terms of the smoking rate for most age groups (data not shown, available on request).
Table 1 Characteristics of study subjects and their crude and age-, survey year-adjusted (standardized to total sample) smoking rates according to gender Women
Men N (%)
No. of smokers (crude smoking rate, %)
2125 (3.7)
52,769 (100.0)
33,085 (62.7)
14,451 (25.2) 16,200 (28.3) 11,372 (19.9) 8767 (15.3) 6456 (11.3)
345 457 349 390 584
13,766 (26.1) 15,727 (29.8) 11,116 (21.1) 7782 (14.8) 4378 (8.3)
9678 (70.3) 10,622 (67.5) 6717 (60.4) 4069 (52.3) 1999 (45.7)
43,990 (76.8) 4165 (7.3)
961 (2.2) 231 (5.6)
2.5 (2.3–2.6) 7.1 (4.4–9.9)
42,527 (80.6) 8107 (15.4)
25,983 (61.1) 5605 (69.1)
62.8 (61.9–63.6) 67.3 (58.1–76.5)
7701 (13.5) 1390 (2.4)
715 (9.3) 218 (15.7)
9.0 (6.2–11.8) 16.0 (13.2–18.9)
903 (1.7) 1232 (2.3)
534 (59.1) 963 (78.2)
75.8 (55.6–96.1) 77.3 (70.5–84.2)
10,177 (17.8)
146 (1.4)
1.6 (1.1–2.0)
17,043 (32.3)
9788 (57.4)
53.8 (52.6–55.0)
20,773 (36.3) 9162 (16.0) 17,134 (29.9)
615 (3.0) 307 (3.4) 1057 (6.2)
3.1 (2.8–3.5) 3.8 (3.0–4.5) 4.4 (3.5–5.3)
21,313 (40.4) 7020 (13.3) 7393 (14.0)
14,474 (67.9) 4406 (62.8) 4417 (59.8)
65.4 (64.3–66.5) 67.3 (64.4–70.2) 68.1 (61.0–75.1)
Occupational class Non-manual 6694 (11.7) Manual 24,249 (42.4) Others 26,303 (46.0)
109 (1.6) 1007 (4.2) 1009 (3.8)
3.3 (1.3–5.3) 4.6 (4.3–4.9) 3.6 (3.4–3.8)
13,615 (25.8) 30,221 (57.3) 8933 (16.9)
7862 (57.8) 20,156 (66.7) 5067 (56.7)
54.5 (53.1–56.0) 67.0 (66.1–67.9) 63.8 (61.7–65.9)
Year* 1999 2003
1120 (4.1) 1005 (3.4)
4.1 (3.9–4.3) 3.4 (3.2–3.6)
25,823 (48.9) 26,946 (51.1)
17,722 (68.6) 15,363 (57.0)
68.4 (67.4–69.4) 57.3 (56.4–58.2)
N (%)
No. of smokers (crude smoking rate, %)
Total
57,246 (100.0)
Age 25–34 35–44 45–54 55–64 65–74 Marital status Married Nevermarried Widowed Divorced Education College or higher High Middle Elementary or less
27,630 (48.3) 29,616 (51.7)
*Adjusted only for age.
Adjusted smoking rate (95% CI)
(2.4) (2.8) (3.1) (4.5) (9.1)
Adjusted smoking rate (95% CI)
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widowed women (Table 3). This difference was smaller for men (Table 4).
Table 2 Marital status according to age and gender Married
Women—age (years) Total 43,990 (76.8) 25–34 10,631 (73.6) 35–44 14,788 (91.3) 45–54 9689 (85.2) 55–64 6134 (70.0) 65–74 2748 (42.6) Men—age (years) Total 42,527 (80.6) 25–34 6902 (50.1) 35–44 13,968 (88.8) 45–54 10,310 (92.8) 55–64 7343 (94.4) 65–74 4004 (91.5)
Nevermarried
Widowed
Divorced
4165 (7.3) 3579 (24.8) 424 (2.6) 120 (1.1) 33 (0.4)
7701 (13.5) 56 (0.4)
1390 (2.4) 185 (1.3)
413 (2.6)
575 (3.6)
1146 (10.1) 2439 (27.8) 3647 (56.5)
417 (3.7)
903 (1.7) 15 (0.1)
1232 (2.3) 116 (0.8)
92 (0.6)
490 (3.1)
9 (0.1)
613
Effects of other variables on smoking rate
161 (1.8)
SEP (education and occupational class) was inversely associated with smoking rates. After adjustment for these variables, PRs for smoking were higher only in the 25–34-year-old age group for women (Table 3). By contrast, for men, adjustment for SEP resulted in a reduction in the PRs for smoking among 35–44 and 45–54-year-olds (Table 4).
52 (0.8)
Discussion Smoking and SEP
8107 (15.4) 6733 (48.9) 1177 (7.5) 174 (1.6) 16 (0.2)
186 (1.7)
446 (4.0)
265 (3.4)
158 (2.0)
7 (0.2)
345 (7.9)
22 (0.5)
Numbers in parentheses represent percent.
Effect of marital status on smoking rate: gender- and age-related differences The smoking rate for unmarried women was approximately 2–8 times higher than for married women depending upon the age group (Table 3). In contrast, the smoking rate for unmarried men was not higher than the married men for the 25–34 and 65–74-year-old age groups (Table 4). According to PR comparisons, the magnitude of the effect of marital status on the smoking rate was greater for women than men. The PRs for smoking in unmarried women were 1.85–7.93 across all ages, with larger gaps associated with those less than 45 years old. By comparison, the PRs for men ranged from 1.00 to 1.17 across all ages (Tables 3 and 4). Smoking rates among the never-married, widowed and divorced In the 35–54-year-old age range, the smoking rate in divorced women was more than twice that of the
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 et al., 2006, 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; Nystadt, 2006; van Loon et al., 2005). The crude divorce rates in Korea were 1.5/1000 person in 1995, 3.5/1000 person in 2003 and 2.6/1000 person in 2006 (Korea National Statistical Office, 2007). Widowhood among women is more prevalent in the elderly due to the large longevity difference between genders in Korea (life expectancy for women and men was 81.9 and 75.1 years in 2005, respectively), which is likely to be due to the large gender gap in smoking (Korea National Statistical Office, 2006). The effect of marital status on smoking according to gender An intriguing finding of the present study was that the difference in the effect of marital status on smoking rate varied according to gender. PRs of smoking rates for unmarried women compared with married women were generally much greater than comparable PRs for men across all age groups, and were particularly high in younger women. This
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Table 3 Age-specific age, survey year-adjusted smoking rates and prevalence ratios (95% confidence interval) adjusting age, survey year, and socioeconomic position by marital status for Korean women (N ¼ 57,246) N (%)
Women aged 25–34 years Married 10,631 (73.6) Unmarried 3820 (26.4) Never-married 3579 (24.8) Widowed 56 (0.4)
No. of smokers (crude smoking rate, %)
139 (1.3) 206 (5.4) 174 (4.9) 6 (10.7)
Adjusted smoking rate (95% CI)
1.4 (1.1–1.6) 6.3 (5.3–7.4) 5.8 (4.7–6.9) o 15.5 (9.4–21.6)
Age- and yearadjusted prevalence ratio (95% CI)
Age-, year-, educationand occupational classadjusted prevalence ratio (95% CI)
1.00 (reference) 4.56 (3.62–5.74) 3.88 (3.05–4.95) 10.07 (7.00–14.48)
1.00 5.94 5.56 7.51
(reference) (4.70–7.52) (4.33–7.15) (5.21–10.83)
Divorced 185 (1.3) Women aged 35–44 years Married 14,788 (91.3) Unmarried 1412 (8.7) Never-married 424 (2.6) Widowed 413 (2.6) Divorced 575 (3.6)
26 (14.1) 261 (1.8) 196 (13.9) 46 (10.9) 40 (9.7) 110 (19.1)
1.8 (1.5–2.0) 14.0 (12.0–16.0) 10.1 (6.8–13.4) 10.0 (6.6–3.4) 18.9 (15.3–22.6)
1.00 (reference) 7.82 (6.55–9.34) 6.36 (4.71–8.59) 5.35 (3.88–7.37) 10.65 (8.65–13.11)
1.00 7.93 8.15 4.93 9.88
(reference) (6.63–9.49) (6.02–11.05) (3.56–6.81) (8.01–12.19)
Women aged 45–54 years Married 9689 (85.2) Unmarried 1683 (14.8) Never-married 120 (1.1) Widowed 1146 (10.1) Divorced 417 (3.7)
215 (2.2) 134 (8.0) 10 (8.3) 69 (6.0) 55 (13.2)
2.2 (1.9–2.5) 8.3 (6.8–9.7) 8.7 (1.5–16.0) 6.1 (4.6–7.6) 13.7 (10.0–17.3)
1.00 3.62 3.87 2.71 6.00
1.00 3.78 5.33 2.75 6.12
(reference) (3.06–4.67) (2.89–9.81) (2.10–3.60) (4.63–8.09)
Women aged 55–64 years Married 6134 (70.0) Unmarried 2633 (30.0) Never-married 33 (0.4) Widowed 2439 (27.8) Divorced 161 (1.8)
193 (3.2) 197 (7.5) 0 (0.0) 179 (7.3) 18 (11.2)
3.2 (2.8–3.7)
1.00 (reference)
1.00 (reference)
o 7.5 (6.4–8.6)
2.31 (1.90–2.80)
2.21 (1.82–2.69)
Women aged 65–74 years Married 2748 (42.6) Unmarried 3708 (57.4) Never-married 9 (0.1) Widowed 3647 (56.5) Divorced 52 (0.8)
153 (5.6) 431 (11.6) 1 (11.1) 421 (11.5) 9 (17.3)
6.0 (5.0–6.9)
1.00 (reference)
1.00 (reference)
o 11.6 (10.5–12.7)
1.96 (1.63–2.34)
1.85 (1.55–2.22)
finding differs from many previous Western studies that reported either no gender difference in the influence of marriage on smoking, or greater difference between married versus unmarried rates in married men compared to married women (Broms et al., 2004; Chandola et al., 2004; Nystadt, 2006; Rice et al., 1996; van Loon et al., 2005). There are a range of possible explanations for the gender-related differences found in the present study. Higher smoking rates in the unmarried may be a reflection of coping in response to stress brought on by marital disruption. Marital disruption can create two types of stress—that which is directly associated with the disruption, and that which is indirectly associated, such as role change,
(reference) (2.93–4.46) (2.10–7.12) (2.08–3.54) (4.54–7.94)
financial difficulties and child caring responsibilities (Stroebe, Stroebe, & Schut, 2001). Women suffer greater financial hardship following marital disruption compared to men, especially in societies where the gender wage gap is high (such as Korea). The average income of female Korean workers was 66.5% of that for male workers in 2005 (Korean Ministry of Gender Equality and Family, 2006) (compared to 77% in the USA (Denavas-Walt, Proctor, & Lee, 2006)). The monthly income of a single-parent family was 54% of a two-parent family, and among them, the income of a womanheaded single-parent family was 83% of a manheaded single-parent family in Korea (Byun, Song, & Kim, 2002). Financial hardship tends to be more
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Table 4 Age-specific age, survey year-adjusted smoking rates and prevalence ratios (95% confidence interval) adjusting age-, survey year-, and socioeconomic position by marital status for Korean men (N ¼ 52,769)
Men aged 25–34 years Married Unmarried Never-married Widowed
N (%)
No. of smokers (crude smoking rate, %)
6902 (50.1) 6864 (49.9) 6733 (48.9) 15 (0.1)
4934 (71.5) 4744 (69.1) 4633 (68.8) 15 (100.0)
Adjusted smoking rate (95% CI)
72.2 70.5 70.1 o 85.6
Age- and yearadjusted prevalence ratio (95% CI)
Age-, year-, educationand occupational classadjusted prevalence ratio (95% CI)
(69.9–74.5) (68.2–72.7) (67.9–72.4) (66.7–100.0)
1.00 0.98 0.98 1.11
(reference) (0.95–1.00) (0.97–0.99) (1.07–1.14)
1.00 1.00 1.00 1.09
(reference) (1.00–1.00) (0.99–1.00) (1.06–1.12)
Divorced Men aged 35–44 years Married Unmarried Never-married Widowed Divorced
116 (0.8)
96 (82.8)
13,968 (88.8) 1759 (11.2) 1177 (7.5) 92 (0.6) 490 (3.1)
9282 (66.5) 1340 (76.2) 853 (72.5) 69 (75.0) 418 (85.3)
66.5 76.9 72.9 74.1 84.8
(65.2–67.9) (72.7–81.2) (67.6–78.3) (53.4–94.7) (76.6–93.1)
1.00 1.14 1.06 1.11 1.16
(reference) (1.10–1.17) (1.05–1.07) (1.09–1.12) (1.14–1.18)
1.00 1.06 1.03 1.08 1.13
(reference) (1.06–1.07) (1.03–1.04) (1.07–1.08) (1.12–1.14)
Men aged 45–54 years Married Unmarried Never-married Widowed Divorced
10,310 (92.8) 806 (7.3) 174 (1.6) 186 (1.7) 446 (4.0)
6153 (59.7) 564 (70.0) 104 (59.8) 129 (69.4) 331 (74.2)
60.1 71.4 56.6 70.7 75.2
(58.6–61.6) (65.3–77.5) (43.8–69.5) (56.5–84.9) (67.0–83.3)
1.00 1.18 1.02 1.14 1.15
(reference) (1.13–1.24) (0.97–1.06) (1.13–1.15) (1.13–1.17)
1.00 1.09 0.98 1.11 1.12
(reference) (1.08–1.10) (0.94–1.03) (1.10–1.12) (1.10–1.13)
Men aged 55–64 years Married Unmarried Never-married Widowed Divorced
7343 (94.4) 439 (5.6) 16 (0.2) 265 (3.4) 158 (2.0)
3793 (51.7) 276 (62.9) 11 (68.8) 158 (59.6) 107 (67.7)
51.6 (50.0–53.2)
1.00 (reference)
1.00 (reference)
o 62.6 (55.0–70.3)
1.22 (1.13–1.31)
1.17 (1.16–1.19)
Men aged 65–74 years Married Unmarried Never-married Widowed Divorced
4004 (91.5) 374 (8.5) 7 (0.2) 345 (7.9) 22 (0.5)
1821 (45.5) 178 (47.6) 4 (57.1) 163 (47.3) 11 (50.0)
46.2 (44.1–48.3)
1.00 (reference)
1.00 (reference)
o 49.3 (41.8–56.7)
1.05 (0.94–1.18)
1.06 (0.95–1.19)
common among widows and female divorcees, and triggered more financially related stress in cases of marital disruption in the USA (Duncan & Hoffman, 1985). Women were more likely than men to continue or return to smoking in the presence of adverse financial events (Mckee, Maciejewski, Falba, & Mazure, 2003). Depression, which is positively related with smoking, was more prevalent in divorced women than divorced men (Simon, 2002). Graham (1994) reported a high smoking rate in single female heads of households with child-caring responsibilities. In Korea, women usually take responsibility for child care after divorce or death of a spouse, which may contribute to increased smoking in women after marital disruption. In
contrast, psychological distress brought on by widowhood has been found to generally affect men more than women (Lee et al., 2005), and widowhood may be more stressful for men than for women (Stroebe et al., 2001). Overall, whether there is a gender-related difference in the degree of negative psychological effects following marital disruption, and whether this is reflected in smoking rates difference between genders in Korea, remains unclear. Being married has a positive influence on health through the maintenance of healthier behavior patterns. In general, the effect of marriage on behavior is stronger for men than women (at least in Western studies) (Umberson, 1992; Westmaas & Wild, 2002), while bereavement and breakup leads to
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the loss of such health protection. Given this gendered pattern reported in the West, we might have anticipated a stronger effect on the smoking rate in divorced and widowed men compared to women. On the contrary, however, the present findings showed a stronger effect on smoking rates in women compared to men after marital disruption. There is a very likely Korea-specific reason for the gender-related differences in smoking rates found in the present study. Despite rapid economic development, Korea is still a very male-dominated society. Women’s relative social status remains quite low, at least as measured by indicators such as the UNDP Gender Empowerment Measure (UNDP, 2006). Under the influence of Confucianism, which emphasizes patriarchal family systems and high levels of control over women, smoking has not been considered to be an acceptable habit of women. Even today, Korean women often feel strong social pressures against smoking in public. In a society where family is still the most important basic social unit, and the relationship between husband and wife is severely tilted against women, smoking by married women is strongly restricted (Chun, Doyal, Payne, & Cho, 2006). Thus, becoming single can paradoxically mean escape from such social restraints on smoking (a ‘‘liberation effect’’). The high smoking rates in men might also have caused a ceiling effect on smoking rates in unmarried men, which could have contributed to the gender difference. However, this cannot explain size of the difference in terms of the effect of marital status on smoking. The level of under-reporting of smoking behavior may vary between countries (West, Zatonski, Przewozniak, & Jarvis, 2007). Women’s smoking can be under-reported in societies where there is a strong social norm against young women adopting such behavior. Such a reporting bias may have affected the findings of this study. Nonetheless, it is not clear whether reporting bias would have produced the differential patterns of smoking rate according to marital status. The results of this study need to be confirmed by verifying under-reporting with biochemical markers of cigarette smoking. The effect of marital status on smoking according to age The present study found that the PRs of smoking rate for unmarried women were inversely related to age (i.e. higher PRs in unmarried young women
than unmarried old women). This trend was not evident in men. In a study of American and French women, the effect of being unmarried on smoking was weaker in the 55–64 compared to the 18–24year-old age group (King et al., 1998). While the findings of the present study may reflect that the loss of a partner is more stressful for young women, we could find no corroborative evidence to support this hypothesis. Rather, divorce or widowhood may remove the inhibitory social control on smoking for Korean women. Such control would be stronger for young women than elderly women. Women’s smoking rates are very low in South Korea and China, where Confucianism and patriarchy still strongly limit women’s sociopolitical status (Khang & Cho, 2006; Yang et al., 1999). In those countries, the smoking rate is higher in older women than younger women. Possible explanations for the positive relationship between age and smoking rate in women may be a cohort effect, an age effect, and/ or under-reporting of smoking among the younger population. Indeed, under-reporting of tobacco use in young women may have been observed in an Indian study (Rani et al., 2003). Older women are likely to more easily overcome restrictive social pressures than younger women (Chun et al., 2006). In Western countries, women’s smoking rates usually show an inverse relationship with age, where younger generations of women have initiated smoking earlier (Graham, 1996). In addition, elderly people quit smoking more frequently because they are more concerned with health. A positive relationship between smoking rate and age in some Asian women may be ascribed to the adoption of smoking first by the elderly (who feel more at liberty to pursue their habit than young women in age-respecting societies). This process is contrary to that which happens in Western countries. Variations in smoking rates according to the type of marital disruption The present study found that, in general, smoking rates were higher for the divorced than for the widowed for both genders, and particularly in women. However, the relationship between type of marital disruption and smoking was not conclusive. Like the present study, a Swedish study found that the smoking rate for the divorced was higher than for the widowed for both genders. There was a lower cessation rate and a higher initiation rate in
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the divorced compared to the widowed for both genders (Nystadt, 2006). However, a USA study reported that the divorced and the widowed were similar in terms of smoking rate, smoking cessation and relapse (Lee et al., 2005). A stronger effect of divorce than widowhood on smoking especially for women may be associated with the increase in depressive symptoms in divorced women (Simon, 2002), and the more frequent use of cigarette smoking as a stress and mood-control device in women (Livson & Leino, 1988). The present study found that the PRs for smoking in the never-married men were similar to or slightly higher than for the married in those less than 55 year old, and were lower than for the widowed or divorced. A study comparing French and Swedish male workers found that the smoking rate for the never-married was higher than for the married and divorced (Kumlin et al., 2001). The data suggest that for Korean men, getting married may not be protective for smoking, but that disruption of marriage can result in more smoking. This also suggests that for women, being unmarried (divorced, widowed or never-married) is an important factor. Further study is required to better understand the role of gender in the effect of different types of marital disruption on smoking. 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 genderrelated difference in the present study. The information gathered by this study was self-reported. Such reporting of smoking habits has been found to be reliable (Wagenknecht, Burke, Perkins, Haley, & Friedman, 1992), and possible misclassification of marital status may lead to a biased underestimate of the effect of marital status on smoking rate. Finally, the study did not gather information regarding the smoking habits and SEP of partners of study subjects which may have influenced the smoking behavior of study subjects (Monden, de Graaf, & Kraaykamp, 2003).
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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 smoking rate in younger women supports this suggestion. A comprehensive tobacco policy in Korea should take into account the impact of marital status and the cultural meaning of gender relations. Alternative approaches to investigation, including in depth qualitative interviews and ethnography—as exemplified by Graham’s (1994) of smoking among lone mothers in Scotland—may reveal deeper reasons for the differential smoking rates among divorced or widowed Korean women. Acknowledgment The authors gratefully acknowledge Dr. SungCheol Yun (Division of Epidemiology and Biostatistics, Clinical Research Center, Asan Medical Center) for statistical support. References Ben-Shlomo, Y., Davey Smith, G., Shipley, M., & Marmot, M. G. (1993). Magnitude and causes of mortality differences between married and unmarried men. Journal of Epidemiology and Community Health, 47, 200–205. Broms, U., Silventoinen, K., Lahelma, E., Koskenvuo, M., & Kaprio, J. (2004). Smoking cessation by socioeconomic status and marital status: The contribution of smoking behavior and family background. Nicotine and Tobacco Research, 6(3), 447–455. Byun, H. S., Song, D. Y., & Kim, Y. R. (2002). A study on current situations and welfare needs according to types of family. Seoul: Korean Women’s Development Institute. Chandola, T., Head, J., & Bartley, M. (2004). Socio-demographic predictors of quitting smoking: How important are household factors? Addiction, 99, 770–777. Cho, H.-J., Khang, Y.-H., & Yun, S.-C. (2006). Occupational differentials in cigarette smoking in South Korea: Findings form the 2003 social statistics survey. Journal of Preventive Medicine and Public Health, 39(4), 365–370. Cho, H.-J., Song, Y. M., Davey Smith, G., & Ebrahim, S. (2004). Trends in socio-economic differentials in cigarette smoking behaviour between 1990 and 1998: A large prospective study in Korean men. Public Health, 118, 553–558.
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Social Science & Medicine 66 (2008) 609–619 www.elsevier.com/locate/socscimed
Marital status and smoking in Korea: The influence of gender and age Hong-Jun Choa,, Young-Ho Khangb, Hee-Jin Junc, Ichiro Kawachid a
Department of Family Medicine, University of Ulsan, College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul 138-736, Republic of Korea b Department of Preventive Medicine, University of Ulsan, College of Medicine, Seoul, Republic of Korea c Channing Laboratory, Brigham & Women’s Hospital/Harvard Medical School, USA d Department of Society, Human Development and Health, Harvard School of Public Health, USA Available online 8 November 2007
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 o45 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. r 2007 Elsevier Ltd. All rights reserved. Keywords: Korea; Smoking; Marital status; Gender; Age
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 Corresponding author. Tel.: +82 2 3010 3812; fax: +82 2 3010 3815. E-mail addresses: [email protected] (H.-J. Cho), [email protected] (Y.-H. Khang), [email protected] (H.-J. Jun), [email protected] (I. Kawachi).
0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2007.10.005
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;
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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 nevermarried) 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
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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. Methods 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. Nonresponse 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 to derive stable smoking rates for women (o5%). Data included 110,015 subjects (57,246 women and 52,769 men) aged from 25 to 74 years.
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Marital status and socioeconomic variables Marital status was categorized as married, nevermarried, widowed or divorced. Education level was classified as elementary school or less, middle school, high school or college or higher. Occupations were based on the South Korean standard for classifying occupations, derived from the International Standard Classification of Occupation (ISCO) of the ILO. Occupations were classified as non-manual or manual. Non-manual occupations included managers, professionals, technicians and clerks, while manual occupations included service and sales workers, agricultural and fishery workers, crafts and related trade workers, plant and machine operators and assemblers, and elementary occupations. Those who were not in the labor market (unemployed, retired, students and homemakers) were categorized as other. Smoking variables The outcome variable for the study was current cigarette smoking measured by the question ‘‘Do you smoke tobacco now?’’ (‘‘Yes, I smoke,’’ ‘‘I smoked before but I quit smoking,’’ or ‘‘I never smoked’’). Respondents who answered, ‘‘Yes, I smoke’’, were categorized as current smokers. Statistical analysis Analyses were performed separately for men and women. Marital status-specific crude smoking rates by age were calculated. These crude smoking rates were directly age standardized to survey year and 5-year age groups, with age distribution of the total sample as the standard, producing survey year- and age-adjusted smoking rates. Confidence intervals (CI) of these adjusted smoking rates were estimated. Estimated prevalence ratios (PRs) (95% CI) were used, instead of odds ratios because the prevalence of the outcome (smoking) violates the ‘‘rare outcome assumption’’ of logistic models in the case of South Korean men. Log binomial regression with PROC GLIMMIX analysis was performed using SAS statistical software. To control the effect of survey year and age, survey year- and age- (within age group)-adjusted PRs according to marital status were calculated. Marital status-specific PRs adjusting for SEPs were also estimated with adjustments for education and occupational class.
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Results 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 nevermarried, 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 among women older than 45 years (Table 2). The average smoking rate for women was 3.7%, and this increased with age, while, the average smoking rate for men was 62.7%, and decreased with age (Table 1). The age-adjusted smoking rate for the unmarried was higher than for the married in both genders, with the highest rate observed in the divorced. Smoking was more prevalent among both men and women with lower SEP (Table 1). There was a significant interaction between gender and marital status in terms of the smoking rate for most age groups (data not shown, available on request).
Table 1 Characteristics of study subjects and their crude and age-, survey year-adjusted (standardized to total sample) smoking rates according to gender Women
Men N (%)
No. of smokers (crude smoking rate, %)
2125 (3.7)
52,769 (100.0)
33,085 (62.7)
14,451 (25.2) 16,200 (28.3) 11,372 (19.9) 8767 (15.3) 6456 (11.3)
345 457 349 390 584
13,766 (26.1) 15,727 (29.8) 11,116 (21.1) 7782 (14.8) 4378 (8.3)
9678 (70.3) 10,622 (67.5) 6717 (60.4) 4069 (52.3) 1999 (45.7)
43,990 (76.8) 4165 (7.3)
961 (2.2) 231 (5.6)
2.5 (2.3–2.6) 7.1 (4.4–9.9)
42,527 (80.6) 8107 (15.4)
25,983 (61.1) 5605 (69.1)
62.8 (61.9–63.6) 67.3 (58.1–76.5)
7701 (13.5) 1390 (2.4)
715 (9.3) 218 (15.7)
9.0 (6.2–11.8) 16.0 (13.2–18.9)
903 (1.7) 1232 (2.3)
534 (59.1) 963 (78.2)
75.8 (55.6–96.1) 77.3 (70.5–84.2)
10,177 (17.8)
146 (1.4)
1.6 (1.1–2.0)
17,043 (32.3)
9788 (57.4)
53.8 (52.6–55.0)
20,773 (36.3) 9162 (16.0) 17,134 (29.9)
615 (3.0) 307 (3.4) 1057 (6.2)
3.1 (2.8–3.5) 3.8 (3.0–4.5) 4.4 (3.5–5.3)
21,313 (40.4) 7020 (13.3) 7393 (14.0)
14,474 (67.9) 4406 (62.8) 4417 (59.8)
65.4 (64.3–66.5) 67.3 (64.4–70.2) 68.1 (61.0–75.1)
Occupational class Non-manual 6694 (11.7) Manual 24,249 (42.4) Others 26,303 (46.0)
109 (1.6) 1007 (4.2) 1009 (3.8)
3.3 (1.3–5.3) 4.6 (4.3–4.9) 3.6 (3.4–3.8)
13,615 (25.8) 30,221 (57.3) 8933 (16.9)
7862 (57.8) 20,156 (66.7) 5067 (56.7)
54.5 (53.1–56.0) 67.0 (66.1–67.9) 63.8 (61.7–65.9)
Year* 1999 2003
1120 (4.1) 1005 (3.4)
4.1 (3.9–4.3) 3.4 (3.2–3.6)
25,823 (48.9) 26,946 (51.1)
17,722 (68.6) 15,363 (57.0)
68.4 (67.4–69.4) 57.3 (56.4–58.2)
N (%)
No. of smokers (crude smoking rate, %)
Total
57,246 (100.0)
Age 25–34 35–44 45–54 55–64 65–74 Marital status Married Nevermarried Widowed Divorced Education College or higher High Middle Elementary or less
27,630 (48.3) 29,616 (51.7)
*Adjusted only for age.
Adjusted smoking rate (95% CI)
(2.4) (2.8) (3.1) (4.5) (9.1)
Adjusted smoking rate (95% CI)
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widowed women (Table 3). This difference was smaller for men (Table 4).
Table 2 Marital status according to age and gender Married
Women—age (years) Total 43,990 (76.8) 25–34 10,631 (73.6) 35–44 14,788 (91.3) 45–54 9689 (85.2) 55–64 6134 (70.0) 65–74 2748 (42.6) Men—age (years) Total 42,527 (80.6) 25–34 6902 (50.1) 35–44 13,968 (88.8) 45–54 10,310 (92.8) 55–64 7343 (94.4) 65–74 4004 (91.5)
Nevermarried
Widowed
Divorced
4165 (7.3) 3579 (24.8) 424 (2.6) 120 (1.1) 33 (0.4)
7701 (13.5) 56 (0.4)
1390 (2.4) 185 (1.3)
413 (2.6)
575 (3.6)
1146 (10.1) 2439 (27.8) 3647 (56.5)
417 (3.7)
903 (1.7) 15 (0.1)
1232 (2.3) 116 (0.8)
92 (0.6)
490 (3.1)
9 (0.1)
613
Effects of other variables on smoking rate
161 (1.8)
SEP (education and occupational class) was inversely associated with smoking rates. After adjustment for these variables, PRs for smoking were higher only in the 25–34-year-old age group for women (Table 3). By contrast, for men, adjustment for SEP resulted in a reduction in the PRs for smoking among 35–44 and 45–54-year-olds (Table 4).
52 (0.8)
Discussion Smoking and SEP
8107 (15.4) 6733 (48.9) 1177 (7.5) 174 (1.6) 16 (0.2)
186 (1.7)
446 (4.0)
265 (3.4)
158 (2.0)
7 (0.2)
345 (7.9)
22 (0.5)
Numbers in parentheses represent percent.
Effect of marital status on smoking rate: gender- and age-related differences The smoking rate for unmarried women was approximately 2–8 times higher than for married women depending upon the age group (Table 3). In contrast, the smoking rate for unmarried men was not higher than the married men for the 25–34 and 65–74-year-old age groups (Table 4). According to PR comparisons, the magnitude of the effect of marital status on the smoking rate was greater for women than men. The PRs for smoking in unmarried women were 1.85–7.93 across all ages, with larger gaps associated with those less than 45 years old. By comparison, the PRs for men ranged from 1.00 to 1.17 across all ages (Tables 3 and 4). Smoking rates among the never-married, widowed and divorced In the 35–54-year-old age range, the smoking rate in divorced women was more than twice that of the
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 et al., 2006, 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; Nystadt, 2006; van Loon et al., 2005). The crude divorce rates in Korea were 1.5/1000 person in 1995, 3.5/1000 person in 2003 and 2.6/1000 person in 2006 (Korea National Statistical Office, 2007). Widowhood among women is more prevalent in the elderly due to the large longevity difference between genders in Korea (life expectancy for women and men was 81.9 and 75.1 years in 2005, respectively), which is likely to be due to the large gender gap in smoking (Korea National Statistical Office, 2006). The effect of marital status on smoking according to gender An intriguing finding of the present study was that the difference in the effect of marital status on smoking rate varied according to gender. PRs of smoking rates for unmarried women compared with married women were generally much greater than comparable PRs for men across all age groups, and were particularly high in younger women. This
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Table 3 Age-specific age, survey year-adjusted smoking rates and prevalence ratios (95% confidence interval) adjusting age, survey year, and socioeconomic position by marital status for Korean women (N ¼ 57,246) N (%)
Women aged 25–34 years Married 10,631 (73.6) Unmarried 3820 (26.4) Never-married 3579 (24.8) Widowed 56 (0.4)
No. of smokers (crude smoking rate, %)
139 (1.3) 206 (5.4) 174 (4.9) 6 (10.7)
Adjusted smoking rate (95% CI)
1.4 (1.1–1.6) 6.3 (5.3–7.4) 5.8 (4.7–6.9) o 15.5 (9.4–21.6)
Age- and yearadjusted prevalence ratio (95% CI)
Age-, year-, educationand occupational classadjusted prevalence ratio (95% CI)
1.00 (reference) 4.56 (3.62–5.74) 3.88 (3.05–4.95) 10.07 (7.00–14.48)
1.00 5.94 5.56 7.51
(reference) (4.70–7.52) (4.33–7.15) (5.21–10.83)
Divorced 185 (1.3) Women aged 35–44 years Married 14,788 (91.3) Unmarried 1412 (8.7) Never-married 424 (2.6) Widowed 413 (2.6) Divorced 575 (3.6)
26 (14.1) 261 (1.8) 196 (13.9) 46 (10.9) 40 (9.7) 110 (19.1)
1.8 (1.5–2.0) 14.0 (12.0–16.0) 10.1 (6.8–13.4) 10.0 (6.6–3.4) 18.9 (15.3–22.6)
1.00 (reference) 7.82 (6.55–9.34) 6.36 (4.71–8.59) 5.35 (3.88–7.37) 10.65 (8.65–13.11)
1.00 7.93 8.15 4.93 9.88
(reference) (6.63–9.49) (6.02–11.05) (3.56–6.81) (8.01–12.19)
Women aged 45–54 years Married 9689 (85.2) Unmarried 1683 (14.8) Never-married 120 (1.1) Widowed 1146 (10.1) Divorced 417 (3.7)
215 (2.2) 134 (8.0) 10 (8.3) 69 (6.0) 55 (13.2)
2.2 (1.9–2.5) 8.3 (6.8–9.7) 8.7 (1.5–16.0) 6.1 (4.6–7.6) 13.7 (10.0–17.3)
1.00 3.62 3.87 2.71 6.00
1.00 3.78 5.33 2.75 6.12
(reference) (3.06–4.67) (2.89–9.81) (2.10–3.60) (4.63–8.09)
Women aged 55–64 years Married 6134 (70.0) Unmarried 2633 (30.0) Never-married 33 (0.4) Widowed 2439 (27.8) Divorced 161 (1.8)
193 (3.2) 197 (7.5) 0 (0.0) 179 (7.3) 18 (11.2)
3.2 (2.8–3.7)
1.00 (reference)
1.00 (reference)
o 7.5 (6.4–8.6)
2.31 (1.90–2.80)
2.21 (1.82–2.69)
Women aged 65–74 years Married 2748 (42.6) Unmarried 3708 (57.4) Never-married 9 (0.1) Widowed 3647 (56.5) Divorced 52 (0.8)
153 (5.6) 431 (11.6) 1 (11.1) 421 (11.5) 9 (17.3)
6.0 (5.0–6.9)
1.00 (reference)
1.00 (reference)
o 11.6 (10.5–12.7)
1.96 (1.63–2.34)
1.85 (1.55–2.22)
finding differs from many previous Western studies that reported either no gender difference in the influence of marriage on smoking, or greater difference between married versus unmarried rates in married men compared to married women (Broms et al., 2004; Chandola et al., 2004; Nystadt, 2006; Rice et al., 1996; van Loon et al., 2005). There are a range of possible explanations for the gender-related differences found in the present study. Higher smoking rates in the unmarried may be a reflection of coping in response to stress brought on by marital disruption. Marital disruption can create two types of stress—that which is directly associated with the disruption, and that which is indirectly associated, such as role change,
(reference) (2.93–4.46) (2.10–7.12) (2.08–3.54) (4.54–7.94)
financial difficulties and child caring responsibilities (Stroebe, Stroebe, & Schut, 2001). Women suffer greater financial hardship following marital disruption compared to men, especially in societies where the gender wage gap is high (such as Korea). The average income of female Korean workers was 66.5% of that for male workers in 2005 (Korean Ministry of Gender Equality and Family, 2006) (compared to 77% in the USA (Denavas-Walt, Proctor, & Lee, 2006)). The monthly income of a single-parent family was 54% of a two-parent family, and among them, the income of a womanheaded single-parent family was 83% of a manheaded single-parent family in Korea (Byun, Song, & Kim, 2002). Financial hardship tends to be more
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Table 4 Age-specific age, survey year-adjusted smoking rates and prevalence ratios (95% confidence interval) adjusting age-, survey year-, and socioeconomic position by marital status for Korean men (N ¼ 52,769)
Men aged 25–34 years Married Unmarried Never-married Widowed
N (%)
No. of smokers (crude smoking rate, %)
6902 (50.1) 6864 (49.9) 6733 (48.9) 15 (0.1)
4934 (71.5) 4744 (69.1) 4633 (68.8) 15 (100.0)
Adjusted smoking rate (95% CI)
72.2 70.5 70.1 o 85.6
Age- and yearadjusted prevalence ratio (95% CI)
Age-, year-, educationand occupational classadjusted prevalence ratio (95% CI)
(69.9–74.5) (68.2–72.7) (67.9–72.4) (66.7–100.0)
1.00 0.98 0.98 1.11
(reference) (0.95–1.00) (0.97–0.99) (1.07–1.14)
1.00 1.00 1.00 1.09
(reference) (1.00–1.00) (0.99–1.00) (1.06–1.12)
Divorced Men aged 35–44 years Married Unmarried Never-married Widowed Divorced
116 (0.8)
96 (82.8)
13,968 (88.8) 1759 (11.2) 1177 (7.5) 92 (0.6) 490 (3.1)
9282 (66.5) 1340 (76.2) 853 (72.5) 69 (75.0) 418 (85.3)
66.5 76.9 72.9 74.1 84.8
(65.2–67.9) (72.7–81.2) (67.6–78.3) (53.4–94.7) (76.6–93.1)
1.00 1.14 1.06 1.11 1.16
(reference) (1.10–1.17) (1.05–1.07) (1.09–1.12) (1.14–1.18)
1.00 1.06 1.03 1.08 1.13
(reference) (1.06–1.07) (1.03–1.04) (1.07–1.08) (1.12–1.14)
Men aged 45–54 years Married Unmarried Never-married Widowed Divorced
10,310 (92.8) 806 (7.3) 174 (1.6) 186 (1.7) 446 (4.0)
6153 (59.7) 564 (70.0) 104 (59.8) 129 (69.4) 331 (74.2)
60.1 71.4 56.6 70.7 75.2
(58.6–61.6) (65.3–77.5) (43.8–69.5) (56.5–84.9) (67.0–83.3)
1.00 1.18 1.02 1.14 1.15
(reference) (1.13–1.24) (0.97–1.06) (1.13–1.15) (1.13–1.17)
1.00 1.09 0.98 1.11 1.12
(reference) (1.08–1.10) (0.94–1.03) (1.10–1.12) (1.10–1.13)
Men aged 55–64 years Married Unmarried Never-married Widowed Divorced
7343 (94.4) 439 (5.6) 16 (0.2) 265 (3.4) 158 (2.0)
3793 (51.7) 276 (62.9) 11 (68.8) 158 (59.6) 107 (67.7)
51.6 (50.0–53.2)
1.00 (reference)
1.00 (reference)
o 62.6 (55.0–70.3)
1.22 (1.13–1.31)
1.17 (1.16–1.19)
Men aged 65–74 years Married Unmarried Never-married Widowed Divorced
4004 (91.5) 374 (8.5) 7 (0.2) 345 (7.9) 22 (0.5)
1821 (45.5) 178 (47.6) 4 (57.1) 163 (47.3) 11 (50.0)
46.2 (44.1–48.3)
1.00 (reference)
1.00 (reference)
o 49.3 (41.8–56.7)
1.05 (0.94–1.18)
1.06 (0.95–1.19)
common among widows and female divorcees, and triggered more financially related stress in cases of marital disruption in the USA (Duncan & Hoffman, 1985). Women were more likely than men to continue or return to smoking in the presence of adverse financial events (Mckee, Maciejewski, Falba, & Mazure, 2003). Depression, which is positively related with smoking, was more prevalent in divorced women than divorced men (Simon, 2002). Graham (1994) reported a high smoking rate in single female heads of households with child-caring responsibilities. In Korea, women usually take responsibility for child care after divorce or death of a spouse, which may contribute to increased smoking in women after marital disruption. In
contrast, psychological distress brought on by widowhood has been found to generally affect men more than women (Lee et al., 2005), and widowhood may be more stressful for men than for women (Stroebe et al., 2001). Overall, whether there is a gender-related difference in the degree of negative psychological effects following marital disruption, and whether this is reflected in smoking rates difference between genders in Korea, remains unclear. Being married has a positive influence on health through the maintenance of healthier behavior patterns. In general, the effect of marriage on behavior is stronger for men than women (at least in Western studies) (Umberson, 1992; Westmaas & Wild, 2002), while bereavement and breakup leads to
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the loss of such health protection. Given this gendered pattern reported in the West, we might have anticipated a stronger effect on the smoking rate in divorced and widowed men compared to women. On the contrary, however, the present findings showed a stronger effect on smoking rates in women compared to men after marital disruption. There is a very likely Korea-specific reason for the gender-related differences in smoking rates found in the present study. Despite rapid economic development, Korea is still a very male-dominated society. Women’s relative social status remains quite low, at least as measured by indicators such as the UNDP Gender Empowerment Measure (UNDP, 2006). Under the influence of Confucianism, which emphasizes patriarchal family systems and high levels of control over women, smoking has not been considered to be an acceptable habit of women. Even today, Korean women often feel strong social pressures against smoking in public. In a society where family is still the most important basic social unit, and the relationship between husband and wife is severely tilted against women, smoking by married women is strongly restricted (Chun, Doyal, Payne, & Cho, 2006). Thus, becoming single can paradoxically mean escape from such social restraints on smoking (a ‘‘liberation effect’’). The high smoking rates in men might also have caused a ceiling effect on smoking rates in unmarried men, which could have contributed to the gender difference. However, this cannot explain size of the difference in terms of the effect of marital status on smoking. The level of under-reporting of smoking behavior may vary between countries (West, Zatonski, Przewozniak, & Jarvis, 2007). Women’s smoking can be under-reported in societies where there is a strong social norm against young women adopting such behavior. Such a reporting bias may have affected the findings of this study. Nonetheless, it is not clear whether reporting bias would have produced the differential patterns of smoking rate according to marital status. The results of this study need to be confirmed by verifying under-reporting with biochemical markers of cigarette smoking. The effect of marital status on smoking according to age The present study found that the PRs of smoking rate for unmarried women were inversely related to age (i.e. higher PRs in unmarried young women
than unmarried old women). This trend was not evident in men. In a study of American and French women, the effect of being unmarried on smoking was weaker in the 55–64 compared to the 18–24year-old age group (King et al., 1998). While the findings of the present study may reflect that the loss of a partner is more stressful for young women, we could find no corroborative evidence to support this hypothesis. Rather, divorce or widowhood may remove the inhibitory social control on smoking for Korean women. Such control would be stronger for young women than elderly women. Women’s smoking rates are very low in South Korea and China, where Confucianism and patriarchy still strongly limit women’s sociopolitical status (Khang & Cho, 2006; Yang et al., 1999). In those countries, the smoking rate is higher in older women than younger women. Possible explanations for the positive relationship between age and smoking rate in women may be a cohort effect, an age effect, and/ or under-reporting of smoking among the younger population. Indeed, under-reporting of tobacco use in young women may have been observed in an Indian study (Rani et al., 2003). Older women are likely to more easily overcome restrictive social pressures than younger women (Chun et al., 2006). In Western countries, women’s smoking rates usually show an inverse relationship with age, where younger generations of women have initiated smoking earlier (Graham, 1996). In addition, elderly people quit smoking more frequently because they are more concerned with health. A positive relationship between smoking rate and age in some Asian women may be ascribed to the adoption of smoking first by the elderly (who feel more at liberty to pursue their habit than young women in age-respecting societies). This process is contrary to that which happens in Western countries. Variations in smoking rates according to the type of marital disruption The present study found that, in general, smoking rates were higher for the divorced than for the widowed for both genders, and particularly in women. However, the relationship between type of marital disruption and smoking was not conclusive. Like the present study, a Swedish study found that the smoking rate for the divorced was higher than for the widowed for both genders. There was a lower cessation rate and a higher initiation rate in
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the divorced compared to the widowed for both genders (Nystadt, 2006). However, a USA study reported that the divorced and the widowed were similar in terms of smoking rate, smoking cessation and relapse (Lee et al., 2005). A stronger effect of divorce than widowhood on smoking especially for women may be associated with the increase in depressive symptoms in divorced women (Simon, 2002), and the more frequent use of cigarette smoking as a stress and mood-control device in women (Livson & Leino, 1988). The present study found that the PRs for smoking in the never-married men were similar to or slightly higher than for the married in those less than 55 year old, and were lower than for the widowed or divorced. A study comparing French and Swedish male workers found that the smoking rate for the never-married was higher than for the married and divorced (Kumlin et al., 2001). The data suggest that for Korean men, getting married may not be protective for smoking, but that disruption of marriage can result in more smoking. This also suggests that for women, being unmarried (divorced, widowed or never-married) is an important factor. Further study is required to better understand the role of gender in the effect of different types of marital disruption on smoking. 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 genderrelated difference in the present study. The information gathered by this study was self-reported. Such reporting of smoking habits has been found to be reliable (Wagenknecht, Burke, Perkins, Haley, & Friedman, 1992), and possible misclassification of marital status may lead to a biased underestimate of the effect of marital status on smoking rate. Finally, the study did not gather information regarding the smoking habits and SEP of partners of study subjects which may have influenced the smoking behavior of study subjects (Monden, de Graaf, & Kraaykamp, 2003).
617
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 smoking rate in younger women supports this suggestion. A comprehensive tobacco policy in Korea should take into account the impact of marital status and the cultural meaning of gender relations. Alternative approaches to investigation, including in depth qualitative interviews and ethnography—as exemplified by Graham’s (1994) of smoking among lone mothers in Scotland—may reveal deeper reasons for the differential smoking rates among divorced or widowed Korean women. Acknowledgment The authors gratefully acknowledge Dr. SungCheol Yun (Division of Epidemiology and Biostatistics, Clinical Research Center, Asan Medical Center) for statistical support. References Ben-Shlomo, Y., Davey Smith, G., Shipley, M., & Marmot, M. G. (1993). Magnitude and causes of mortality differences between married and unmarried men. Journal of Epidemiology and Community Health, 47, 200–205. Broms, U., Silventoinen, K., Lahelma, E., Koskenvuo, M., & Kaprio, J. (2004). Smoking cessation by socioeconomic status and marital status: The contribution of smoking behavior and family background. Nicotine and Tobacco Research, 6(3), 447–455. Byun, H. S., Song, D. Y., & Kim, Y. R. (2002). A study on current situations and welfare needs according to types of family. Seoul: Korean Women’s Development Institute. Chandola, T., Head, J., & Bartley, M. (2004). Socio-demographic predictors of quitting smoking: How important are household factors? Addiction, 99, 770–777. Cho, H.-J., Khang, Y.-H., & Yun, S.-C. (2006). Occupational differentials in cigarette smoking in South Korea: Findings form the 2003 social statistics survey. Journal of Preventive Medicine and Public Health, 39(4), 365–370. Cho, H.-J., Song, Y. M., Davey Smith, G., & Ebrahim, S. (2004). Trends in socio-economic differentials in cigarette smoking behaviour between 1990 and 1998: A large prospective study in Korean men. Public Health, 118, 553–558.
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