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The contribution of lone parenthood and economic difficulties to smoking
ARTICLE IN PRESS
Social Science & Medicine 61 (2005) 211–216 www.elsevier.com/locate/socscimed
The contribution of lone parenthood and economic difficulties to smoking Ossi Rahkonena,, Mikko Laaksonenb, Sakari Karvonenc a
Department of Social Policy, Box 18, University of Helsinki, 00014 Finland Department of Public Health, Box 41, University of Helsinki, 00014 Finland c Stakes, National Research and Development Centre for Welfare and Health, Box 220, 00531 Helsinki, Finland b
Available online 8 January 2005
Abstract Smoking is more prevalent among lower socioeconomic status groups, among those who perceive economic difficulties and among lone mothers. Less is known of how these factors contribute to smoking independently. The aim of this study was first to examine the association between smoking and both economic difficulties and lone parenthood. We then also studied to what extent smoking among people experiencing economic difficulties and lone parenthood is due to other factors such as socioeconomic status and social relations. The data derive from surveys conducted among the employees of the City of Helsinki, Finland, in 2000 and 2001 including 6243 respondents aged 40–60 yr (response rate 68%). The measures were daily smoking, economic difficulties and family type, as well as socioeconomic status (education, occupational social class, household income, housing tenure) and social relations. The more had respondents experienced economic difficulties, the more prevalent was their smoking. Smoking among lone parents was more common than among parents living together; this was true for both men and women. After controlling for socioeconomic status and housing tenure, the association between smoking and economic difficulties, as well as that between smoking and lone parenthood, attenuated but remained statistically significant. However, after controlling for social relations the associations became stronger. Both economic difficulties and lone parenthood were associated with smoking independent of education, occupational social class, household disposable income, housing tenure or social relations for both men and women. r 2004 Elsevier Ltd. All rights reserved. Keywords: Smoking; Lone parenthood; Economic difficulties; Socioeconomic status; Finland
Introduction Smoking seems to be associated with several kinds of disadvantage, such as material (poverty, unemployment, homelessness), social (loneliness, divorce), cultural (immigrants, ethnic groups) as well as regional (living on Corresponding author. Tel.: +358 9 19124579; fax: +358 9 19124564. E-mail address: ossi.rahkonen@helsinki.fi (O. Rahkonen).
the periphery) disadvantage (Graham, 1995; Stronks, van de Mheen, Looman, & Mackenbach, 1997; Jarvis & Wardle, 1999; Dorsett, 1999; Laaksonen, Rahkonen, Karvonen, & Lahelma, forthcoming). It seems that those who have the least disposable money smoke most but this association may result from the particularly high smoking rates of the most unfortunate ones. The aim of this study was to investigate whether the association between smoking and disadvantage also holds true among those relatively better-off, among
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people who are employed and live in Helsinki, in the capital of Finland. The more specific questions were:
Is smoking related to economic difficulties and lone
parenthood among the employees of the City of Helsinki? Do economic difficulties and lone parenthood contribute to smoking independently? To what extent is the association between smoking and economic difficulties or lone parenthood due to other factors?
This study used baseline data gathered in two separate surveys in 2000 and 2001. Employers’ records were used to identify all employees of the City of Helsinki. A selfadministered questionnaire was sent to all employees who reached the age of 40, 45, 50, 55 or 60 at the year of the survey. The overall response rate was 68% in both years. The total number of respondents was 6243, of whom 80% were women. The non-response analysis showed that the respondents correspond to the target population reasonably well (Lallukka et al., 2002). Smoking
Previous studies have emphasised such factors as socioeconomic status, education, household income, housing tenure and social relations as determinants of smoking. These factors are highly inter-related. As lone parenthood, especially lone motherhood is related to economic hardship (Dorsett, 1999; OECD, 2001; Hope, Power, & Rodgers, 1999) we hypothesised the association between smoking and lone parenthood to be arbitrary and to be explained by the low socioeconomic status and the economic hardship experienced by lone mothers as well as their lack of social relations. We also expected the association between smoking and economic hardship to be largely explained by socioeconomic status, especially by household income. Finland provides an interesting case when studying the associations between smoking, economic difficulties and lone parenthood. Comprehensive tobacco control has been exercised for nearly 30 yr and currently there is a very progressive Tobacco Act, including a total advertising ban, prohibition of the sale of tobacco products to minors, smoke-free public premises and public transport and prohibition of smoking in work places. The latest rates were lowest in Finland in Europe with 26% of men and 19% women smoking daily (Helakorpi, Patja, Pra¨tta¨la¨, Aro, & Uutela, 2003; Leppo & Puska, 2003). Women’s full-time labour participation is almost as high as that of men, universal social benefits are prominent, and income inequalities are one of the lowest in the OECD countries (OECD, 2001).
Material and methods The data were drawn from the Helsinki Health Study (Kivela¨ et al., 2001), which concentrates on socioeconomic and other determinants of health and well being among middle-aged men and women employed by the City of Helsinki. The City of Helsinki is a large employer with nearly 40,000 employees. In addition to general administration, most people work in social and health care, education and culture, public transport, and in the technical and construction sectors.
Respondents were asked: ‘‘Do you smoke cigarettes, cigars or pipe daily?’’ with simply two response alternatives, yes and no. One-fifth of women and almost one-third of men were daily smokers. Smokers were primarily cigarette smokers, and only about 1% of men and 0.1% of women smoked pipe or cigars. Economic difficulties and lone parenthood Economic difficulties were elicited by two questions: ‘‘How often do you have enough money to buy food or clothes that you or your family need?’’ and ‘‘How often do you have difficulties in paying your bills?’’ Both of these questions had five response alternatives. These two questions were combined into one indicator with four categories indicating no economic difficulties (49%), some economic difficulties (27%), many economic difficulties (14%) and very many economic difficulties (10%). Household type was constructed using information on marital status and having dependent children in the household. Household type was categorised into four groups: lone parent (among women 8%, among men 3%), single (not married, no children) (among women 19%, among men 17%), married, no dependent children (among women 37%, among men 43%) and married with dependent children (among women 36%, among men 38%). Educational attainment was measured by a question asking about completed general or vocational education. Education was divided into three groups that correspond to basic (compulsory) education (less than 10 yr), secondary education (10–12 yr) and higher education (university degree) (more than 12 yr). In all, 44% of women and 41% of men had only the basic education. More men (32%) than women (24%) had a higher education. Occupational class consisted of five hierarchical groups: managers, professionals, semi-professionals, routine non-manuals, and manual workers. Manual workers and non-manual employees were separated using the socioeconomic classification of Statistics
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Finland (Statistics Finland, 1989) and non-manual employees were further divided into four groups according to the occupational classification of the City of Helsinki. There were fewer women than men among the managers. The professionals and semi-professionals accounted for between 17% and 26% and these classes were of relatively equal size among men and women. However, the routine non-manual class was the largest among women (43%), but only accounted for 11% of men. On the contrary, the manual class was the largest class among men (28%), but only accounted for 11% of women. Income data were obtained from the questionnaire by asking the respondents to estimate their household income during a typical month, excluding taxes and including welfare benefits. This information was converted into household equivalent income, which takes into account household size and compositions. Weights of the modified OECD equivalence scale were used: the respondent 1, other adults 0.5 and children 0.3 (Hagenaars, de Vos, & Zaidi, 1994). Household equivalent income was divided into quartiles separately for women and men. Housing tenure was divided into four categories: owner–occupier (66%), free-market renter (20%), renter from the employer (the City of Helsinki) (10%), and other (4%). The frequency of social relations was elicited from two combined questions, where the first question was ‘How often do you meet relatives outside your household?’ and the second one ‘How often do you see friends or acquaintances? (not necessarily the same person each time)’. The frequency of social relations was studied in three groups: daily, weekly and more seldom. In all, 72% of women and 66% of men met their relatives or friends at least weekly.
Statistical methods We first present the age-adjusted prevalence of regular smoking with 95% confidence intervals by economic difficulties and lone parenthood as well as the background variables. Logistic regression analysis was used to fit models where the effects of economic difficulties and lone parenthood on smoking were examined controlling for the background variables. Economic difficulties and household type were first included separately. In the second stage economic difficulties and household type were included simultaneously. Other factors were then introduced in the models step-by-step, first by factors describing socioeconomic status (education, occupation and household income), then housing tenure and finally social relations. The results are presented as ageadjusted odds ratios (OR) and their 95% confidence
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intervals. All analyses were performed separately for men and women.
Results The prevalence of regular smoking among the employees in the City of Helsinki was 22% for women and 29% for men. A clear gradient was found in smoking according to economic difficulties (Table 1). More than a third (37%) of women and a half (52%) of men who reported having too many economic difficulties were smokers. The respective figures for those who had no economic difficulties were 18% and 24%. Table 1 Age-adjusted prevalence of regular smoking by sociodemographic factors (% and 95% CI) Women
Men
Economic difficulties Too many Many Some Not at all
37 26 24 18
(32–41) (23–30) (22–26) (16–19)
52 34 27 24
(41–63) (27–41) (23–32) (21–28)
Household type Lone parent Single Married, no children Married, with children
26 26 27 15
(22–30) (23–29) (24–30) (13–17)
48 36 32 32
(28–67) (29–42) (26–37) (26–37)
Socioeconomic status Manual worker Routine non-manual Semi-professional Professional Manager
38 26 18 13 14
(34–42) (25–28) (16–21) (11–15) (11–18)
35 42 24 27 16
(30–40) (34–50) (19–30) (22–32) (17–21)
Household income Lowest quartile Second quartile Third quartile Highest quartile
29 23 22 17
(27–32) (20–25) (19–24) (15–19)
39 29 24 23
(33–44) (24–34) (19–29) (17–28)
Education Basic Secondary Highest
31 (29–33) 20 (18–22) 13 (11–15)
37 (32–41) 25 (20–29) 23 (19–27)
Housing tenure Renter (from the employer) Renter (free market) Other Owner occupied
37 33 20 16
50 45 34 20
Social relations Daily Weekly Seldom
26 (23–29) 22 (20–24) 21 (19–23)
(34–40) (28–37) (15–25) (15–18)
(43–57) (36–53) (23–45) (18–23)
34 (27–40) 28 (24–32) 26 (22–31)
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Married mothers smoked less often than those living in other family types. However, there were no differences between other family types. Smoking among lone fathers was exceptionally high, 48%, among married fathers the corresponding figure was 32%. A gradient was found in smoking by all socioeconomic status measures. The lower the status, the higher the prevalence of smoking regardless of whether the measure of socioeconomic status was occupation, education or household income. An exception was routine non-manual men who smoked as often as manual men. It should also be noticed that manual women smoked as often as manual men. Also among managers there were no gender differences in smoking. Smoking was most prevalent among renters, a third (33–37%) of female renters and a half (45–50%) of male renters smoked. There were no differences between those who were free-market renters or renters from the employer (City of Helsinki). Smoking was least prevalent among women (16%) and men (20%) living in owner-occupied housing. Those who met their relatives or friends daily were more likely to be smokers than those who met their relatives and friends less often. Logistic regression analysis was used to study whether the other factors explained the associations of economic difficulties and household type with smoking. In the first model economic difficulties and household type were included separately. Among those who reported very many economic difficulties, and among lone parents, smoking was clearly higher than in the reference categories. In the second stage, economic difficulties and household type were included simultaneously. The association between smoking and economic difficulties remained stable, whereas the association between smoking and lone parenthood attenuated but remained strong
(Tables 2 and 3). In the following model education, occupational social class and income were included. The association between smoking and economic difficulties as well as the association between smoking and lone parenthood weakened but remained statistically significant. When housing tenure was included in the model among men, the associations between smoking and economic difficulties (OR ¼ 1.45) and between smoking and lone parenthood (OR ¼ 1.79) were no longer statistically significant (Table 3) but there were only 34 lone fathers in our data. Also the association between smoking and other types of household disappeared among men. Finally, after including social relations in the model both associations became stronger. All pairwise interactions between the study variables were checked. An interaction between family type and social relations was observed (for women p ¼ 0:04; for men p ¼ 0:003). The interaction showed that the association between smoking and family type existed only among mothers (both lone parents and the married) but not among the single or women living with a partner only. Women without children were not frequent smokers even if they had frequent social relations. In men, the interaction between family type and social relations was not consistent.
Discussion In this study we sought to examine whether there is an independent association between smoking and economic difficulties and between smoking and lone parenthood. We focused on the relatively better-off: middle-aged women and men who were employed and lived in Helsinki, the capital of Finland.
Table 2 Logistic regression analyses of the association between smoking and social background among women, age-adjusted odds ratios (OR) and 95% CI Women
Economic difficulties Too many Many Some Not at all Household type Lone parent Single Married, no children Married, with children
Economic difficulties and household type
Economic difficulties or household type
+Socioeconomic status (education, occupation, income)
+Housing tenure
+Social relations
2.88 (2.29–3.63) 1.63 (1.31–2.04) 1.47 (1.23–1.75) 1.00
2.81 (2.22–3.56) 1.60 (1.28–2.00) 1.45 (1.21–1.73) 1.00
2.23 (1.74–2.86) 1.35 (1.07–1.70) 1.29 (1.07–1.55) 1.00
1.88 (1.46–2.43) 1.22 (0.97–1.54) 1.21 (1.00–1.45) 1.00
2.28 (1.78–2.93) 1.39 (1.10–1.75) 1.32 (1.10–1.59) 1.00
2.23 (1.72–2.88) 1.88 (1.50–2.34) 1.80 (1.47–2.21) 1.00
1.83 (1.40–2.38) 1.82 (1.45–2.27) 1.91 (1.55–2.35) 1.00
1.74 (1.33–2.28) 1.84 (1.45–2.35) 1.79 (1.44–2.23) 1.00
1.47 (1.11–1.94) 1.58 (1.24–2.03) 1.66 (1.32–2.07) 1.00
1.71 (1.30–2.24) 1.77 (1.39–2.25) 1.81 (1.45–2.26) 1.00
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Table 3 Logistic regression analyses of the association between smoking and social background among men, age-adjusted odds ratios (OR) and 95% CI Men
Economic difficulties Too many Many Some Not at all Household type Lone parent Single Married, no children Married, with children
Economic difficulties and household type
Economic difficulties or household type
+Socioeconomic status (education, occupation, income)
+Housing tenure
+Social relations
2.69 (1.66–4.37) 1.60 (1.09–2.35) 1.27 (0.92–1.76) 1.00
2.44 (1.49–4.01) 1.57 (1.06–2.32) 1.31 (0.95–1.82) 1
1.86 (1.10–3.12) 1.27 (0.85–1.90) 1.12 (0.80–1.57) 1.00
1.45 (0.85–2.48) 1.08 (0.71–1.64) 1.06 (0.75–1.49) 1.00
1.89 (1.12–3.17) 1.28 (0.86–1.92) 1.13 (0.80–1.58) 1.00
3.65 (1.65–8.10) 1.73 (1.18–2.54) 1.38 (0.98–1.94) 1.00
2.98 (1.32–6.73) 1.68 (1.14–2.48) 1.41 (1.00–2.00) 1.00
2.39 (1.04–5.48) 1.56 (1.04–2.34) 1.35 (0.94–1.94) 1.00
1.79 (0.75–4.24) 1.03 (0.67–1.59) 1.27 (0.88–1.84) 1.00
2.34 (1.02–5.40) 1.49 (0.99–2.24) 1.36 (0.95–1.94) 1.00
The first result of our study was that smoking was clearly more common among lone parents than among married parents, even after adjusting for economic difficulties, socioeconomic status and social relations. Smoking was exceptionally high among lone fathers (48%). Lone fathers have been neglected in health research probably because their numbers are quite low. Our results differ from those found in the UK where smoking was not more common among lone fathers than their married counterparts (Jarvis & Wardle, 1999). Another important result of our study was that women and men having too many economic difficulties smoked twice as often as men and women having no economic difficulties, even when differences in socioeconomic status, household type and social relations were taken into account. We expected this association to disappear when income was adjusted for, but income explained among women only about one-fifth and among men about a half of the relationship between smoking and economic difficulties and the association between economic difficulties and smoking remained statistically significant. Housing tenure explained more than income (59% among men, 42% among women) but even after adjusting for several indicators of socioeconomic status and social relations the association between smoking and lone parenthood as well as smoking and economic difficulties remained. Economic difficulties are common in lone-parent households (Dorsett, 1999; OECD, 2001). Contrary to our expectation, adjusting for economic difficulties did not level off the association between smoking and lone parenthood. Thus, the third important finding in our study was that lone parenthood and economic difficulties are independently related to smoking. This held true for both women and men.
It should be noticed that we did not examine the most disadvantaged people, since all respondents were employed and lived in the capital area. Further, the respondents cannot be considered socially disadvantaged as most of them met their friends and relatives often. Our data were cross-sectional, thus no conclusions should be interpreted from causal relationships. It is possible that smoking and economic difficulties affect each other (Shiapush, Borland, & Scollo, 2003). Smoking in Finland is so expensive (one package of 20 cigarettes cost about 4 Euros) that it can significantly affect the money spent for basic necessities even among employed population. Economic difficulties may also cause additional stress that induce smoking. However, it is not very plausible that smoking affects lone parenthood. Our study showed that smoking is associated with social relations. Social networks seem to encourage smoking so that particularly among lone parents smoking seems to be an important part of social life. Thus, even though social relations are generally considered positive to health, in some contexts they might also include negative consequences. In some subcultures, smoking is considered positive and there may even be a normative pressure to smoke (Stead, MacAskill, MacKintosh, Reece, & Eadie, 2001). Such subcultures may be quite resistant to anti-smoking health promotion. The association between smoking and economic difficulties and lone parenthood shows that smoking is related to welfare deficits also among the employed population. Smoking seems to play a part in the accumulation of deprivation so that those who have economic difficulties also have a higher risk of poor health due to smoking. A Scottish in-depth interview
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study reported that many smokers from a disadvantaged area wanted to quit, but they emphasised the stressfulness of their lives and an addiction to smoking that hampered quitting (Wiltshire, Bancroft, Amos, & Parry, 2001). To facilitate smoking cessation, the interventions certainly should tackle the material circumstances of disadvantaged smokers (Lawlor, Frankel, Shaw, Ebrahim, & Davey Smith, 2003) as well as with nicotine addiction, but also with specific interventions on subcultures and social networks where smoking is acceptable and supported.
Acknowledgements The Helsinki Health Study is supported by the Academy of Finland (#45664, #48118 and #53245), and the Finnish Work Environment Fund (#99090). We thank all participating employees of the City of Helsinki and members of the Helsinki Health Study group.
References Dorsett, R. (1999). An econometric analysis of smoking prevalence among lone mothers. Journal of Health Economics, 18, 429–441. Graham, H. (1995). Cigarette smoking: a light on gender and class inequality in Britain. Journal of Social Policy, 24, 509–527. Hagenaars, A., de Vos, K., & Zaidi, M. A. (1994). Poverty statistics in the late 1980s: research based on micro-data. Luxenburg: Office for Official Publications of the European Communities. Helakorpi, S., Patja, K., Pra¨tta¨la¨, R., Aro, A., & Uutela, A. (2003). Health behaviour among Finnish adult population, Spring 2003. Helsinki: Publications of the National Public Health Institute B 17. Hope, S., Power, C., & Rodgers, B. (1999). Does financial hardship account for elevated psychological distress in lone mothers? Social Science & Medicine, 49, 1637–1649. Jarvis, M. J., & Wardle, J. (1999). Social patterning of individual health behaviours: the case of cigarette smoking.
In M. Marmot, & R. G. Wilkinson (Eds.), Social Determinants of Health (pp. 240–255). Oxford: Oxford University Press. Kivela¨, K., Roos, E., Lahelma, E., Lallukka, T., Martikainen, P., Rahkonen, O., Sarlio-La¨hteenkorva, S., & Silventoinen, K. (2001). Henkilo¨sto¨n tyo¨olot, terveydentila ja terveyska¨ytta¨ytyminen. Helsingin kaupungin henkilo¨sto¨n terveystutkimus. (Working conditions, health status and health behaviour among employees. The Helsinki Health Study.) Helsinki: City of Helsinki Urban Facts, research reports 3. Laaksonen M., Rahkonen O., Karvonen S., & Lahelma E. (forthcoming). Socioeconomic status and smoking: analysing inequalities with multiple indicators. European Journal of Public Health, forthcoming. Lallukka, T., Aittoma¨ki, A., Piha, K., Roos, E., Kivela¨, K., & Silventoinen, K. (2002). Postikyselytutkimukseen vastanneiden edustavuus sosioekonomisten tekijo¨iden ja sairauspoissaolotietojen mukaan (Associations of socio-economic factors and sickness absence with participation in a health survey). Sosiaalila¨a¨ketieteellinen Aikakauslehti (Finnish Journal of Social Medicine), 39, 164–171. Lawlor, D. A., Frankel, S., Shaw, M., Ebrahim, S., & Davey Smith, G. (2003). Smoking and ill health: does lay epidemiology explain the failure of smoking cessation programs among deprived populations? American Journal of Public Health, 93, 266–270. Leppo, K., & Puska, P. (2003). Tobacco control in Finland. Finnish Medical Journal, 58, 2953–2957. Shiapush, M., Borland, R., & Scollo, M. (2003). Smoking and financial stress. Tobacco Control, 12, 60–66. Statistics Finland. (1989). Classification of socio-economic groups. Handbooks 17. Helsinki: Central Statistical Office of Finland. Stead, M., MacAskill, S., MacKintosh, A.-M., Reece, J., & Eadie, D. (2001). It’s as if you’re locked in: qualitative explanations for area effects on smoking in disadvantaged communities. Health & Place, 7, 333–343. Stronks, K., van de Mheen, H. D., Looman, C. W., & Mackenbach, J. P. (1997). Cultural, material, and psychosocial correlates of the socio-economic gradient in smoking behavior among adults. Preventive Medicine, 26, 754–766. Wiltshire, S., Bancroft, A., Amos, A., & Parry, O. (2001). They’re doing people a service—qualitative study of smoking, smuggling and social deprivation. British Medical Journal, 323, 203–207.
Social Science & Medicine 61 (2005) 211–216 www.elsevier.com/locate/socscimed
The contribution of lone parenthood and economic difficulties to smoking Ossi Rahkonena,, Mikko Laaksonenb, Sakari Karvonenc a
Department of Social Policy, Box 18, University of Helsinki, 00014 Finland Department of Public Health, Box 41, University of Helsinki, 00014 Finland c Stakes, National Research and Development Centre for Welfare and Health, Box 220, 00531 Helsinki, Finland b
Available online 8 January 2005
Abstract Smoking is more prevalent among lower socioeconomic status groups, among those who perceive economic difficulties and among lone mothers. Less is known of how these factors contribute to smoking independently. The aim of this study was first to examine the association between smoking and both economic difficulties and lone parenthood. We then also studied to what extent smoking among people experiencing economic difficulties and lone parenthood is due to other factors such as socioeconomic status and social relations. The data derive from surveys conducted among the employees of the City of Helsinki, Finland, in 2000 and 2001 including 6243 respondents aged 40–60 yr (response rate 68%). The measures were daily smoking, economic difficulties and family type, as well as socioeconomic status (education, occupational social class, household income, housing tenure) and social relations. The more had respondents experienced economic difficulties, the more prevalent was their smoking. Smoking among lone parents was more common than among parents living together; this was true for both men and women. After controlling for socioeconomic status and housing tenure, the association between smoking and economic difficulties, as well as that between smoking and lone parenthood, attenuated but remained statistically significant. However, after controlling for social relations the associations became stronger. Both economic difficulties and lone parenthood were associated with smoking independent of education, occupational social class, household disposable income, housing tenure or social relations for both men and women. r 2004 Elsevier Ltd. All rights reserved. Keywords: Smoking; Lone parenthood; Economic difficulties; Socioeconomic status; Finland
Introduction Smoking seems to be associated with several kinds of disadvantage, such as material (poverty, unemployment, homelessness), social (loneliness, divorce), cultural (immigrants, ethnic groups) as well as regional (living on Corresponding author. Tel.: +358 9 19124579; fax: +358 9 19124564. E-mail address: ossi.rahkonen@helsinki.fi (O. Rahkonen).
the periphery) disadvantage (Graham, 1995; Stronks, van de Mheen, Looman, & Mackenbach, 1997; Jarvis & Wardle, 1999; Dorsett, 1999; Laaksonen, Rahkonen, Karvonen, & Lahelma, forthcoming). It seems that those who have the least disposable money smoke most but this association may result from the particularly high smoking rates of the most unfortunate ones. The aim of this study was to investigate whether the association between smoking and disadvantage also holds true among those relatively better-off, among
0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2004.11.044
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people who are employed and live in Helsinki, in the capital of Finland. The more specific questions were:
Is smoking related to economic difficulties and lone
parenthood among the employees of the City of Helsinki? Do economic difficulties and lone parenthood contribute to smoking independently? To what extent is the association between smoking and economic difficulties or lone parenthood due to other factors?
This study used baseline data gathered in two separate surveys in 2000 and 2001. Employers’ records were used to identify all employees of the City of Helsinki. A selfadministered questionnaire was sent to all employees who reached the age of 40, 45, 50, 55 or 60 at the year of the survey. The overall response rate was 68% in both years. The total number of respondents was 6243, of whom 80% were women. The non-response analysis showed that the respondents correspond to the target population reasonably well (Lallukka et al., 2002). Smoking
Previous studies have emphasised such factors as socioeconomic status, education, household income, housing tenure and social relations as determinants of smoking. These factors are highly inter-related. As lone parenthood, especially lone motherhood is related to economic hardship (Dorsett, 1999; OECD, 2001; Hope, Power, & Rodgers, 1999) we hypothesised the association between smoking and lone parenthood to be arbitrary and to be explained by the low socioeconomic status and the economic hardship experienced by lone mothers as well as their lack of social relations. We also expected the association between smoking and economic hardship to be largely explained by socioeconomic status, especially by household income. Finland provides an interesting case when studying the associations between smoking, economic difficulties and lone parenthood. Comprehensive tobacco control has been exercised for nearly 30 yr and currently there is a very progressive Tobacco Act, including a total advertising ban, prohibition of the sale of tobacco products to minors, smoke-free public premises and public transport and prohibition of smoking in work places. The latest rates were lowest in Finland in Europe with 26% of men and 19% women smoking daily (Helakorpi, Patja, Pra¨tta¨la¨, Aro, & Uutela, 2003; Leppo & Puska, 2003). Women’s full-time labour participation is almost as high as that of men, universal social benefits are prominent, and income inequalities are one of the lowest in the OECD countries (OECD, 2001).
Material and methods The data were drawn from the Helsinki Health Study (Kivela¨ et al., 2001), which concentrates on socioeconomic and other determinants of health and well being among middle-aged men and women employed by the City of Helsinki. The City of Helsinki is a large employer with nearly 40,000 employees. In addition to general administration, most people work in social and health care, education and culture, public transport, and in the technical and construction sectors.
Respondents were asked: ‘‘Do you smoke cigarettes, cigars or pipe daily?’’ with simply two response alternatives, yes and no. One-fifth of women and almost one-third of men were daily smokers. Smokers were primarily cigarette smokers, and only about 1% of men and 0.1% of women smoked pipe or cigars. Economic difficulties and lone parenthood Economic difficulties were elicited by two questions: ‘‘How often do you have enough money to buy food or clothes that you or your family need?’’ and ‘‘How often do you have difficulties in paying your bills?’’ Both of these questions had five response alternatives. These two questions were combined into one indicator with four categories indicating no economic difficulties (49%), some economic difficulties (27%), many economic difficulties (14%) and very many economic difficulties (10%). Household type was constructed using information on marital status and having dependent children in the household. Household type was categorised into four groups: lone parent (among women 8%, among men 3%), single (not married, no children) (among women 19%, among men 17%), married, no dependent children (among women 37%, among men 43%) and married with dependent children (among women 36%, among men 38%). Educational attainment was measured by a question asking about completed general or vocational education. Education was divided into three groups that correspond to basic (compulsory) education (less than 10 yr), secondary education (10–12 yr) and higher education (university degree) (more than 12 yr). In all, 44% of women and 41% of men had only the basic education. More men (32%) than women (24%) had a higher education. Occupational class consisted of five hierarchical groups: managers, professionals, semi-professionals, routine non-manuals, and manual workers. Manual workers and non-manual employees were separated using the socioeconomic classification of Statistics
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Finland (Statistics Finland, 1989) and non-manual employees were further divided into four groups according to the occupational classification of the City of Helsinki. There were fewer women than men among the managers. The professionals and semi-professionals accounted for between 17% and 26% and these classes were of relatively equal size among men and women. However, the routine non-manual class was the largest among women (43%), but only accounted for 11% of men. On the contrary, the manual class was the largest class among men (28%), but only accounted for 11% of women. Income data were obtained from the questionnaire by asking the respondents to estimate their household income during a typical month, excluding taxes and including welfare benefits. This information was converted into household equivalent income, which takes into account household size and compositions. Weights of the modified OECD equivalence scale were used: the respondent 1, other adults 0.5 and children 0.3 (Hagenaars, de Vos, & Zaidi, 1994). Household equivalent income was divided into quartiles separately for women and men. Housing tenure was divided into four categories: owner–occupier (66%), free-market renter (20%), renter from the employer (the City of Helsinki) (10%), and other (4%). The frequency of social relations was elicited from two combined questions, where the first question was ‘How often do you meet relatives outside your household?’ and the second one ‘How often do you see friends or acquaintances? (not necessarily the same person each time)’. The frequency of social relations was studied in three groups: daily, weekly and more seldom. In all, 72% of women and 66% of men met their relatives or friends at least weekly.
Statistical methods We first present the age-adjusted prevalence of regular smoking with 95% confidence intervals by economic difficulties and lone parenthood as well as the background variables. Logistic regression analysis was used to fit models where the effects of economic difficulties and lone parenthood on smoking were examined controlling for the background variables. Economic difficulties and household type were first included separately. In the second stage economic difficulties and household type were included simultaneously. Other factors were then introduced in the models step-by-step, first by factors describing socioeconomic status (education, occupation and household income), then housing tenure and finally social relations. The results are presented as ageadjusted odds ratios (OR) and their 95% confidence
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intervals. All analyses were performed separately for men and women.
Results The prevalence of regular smoking among the employees in the City of Helsinki was 22% for women and 29% for men. A clear gradient was found in smoking according to economic difficulties (Table 1). More than a third (37%) of women and a half (52%) of men who reported having too many economic difficulties were smokers. The respective figures for those who had no economic difficulties were 18% and 24%. Table 1 Age-adjusted prevalence of regular smoking by sociodemographic factors (% and 95% CI) Women
Men
Economic difficulties Too many Many Some Not at all
37 26 24 18
(32–41) (23–30) (22–26) (16–19)
52 34 27 24
(41–63) (27–41) (23–32) (21–28)
Household type Lone parent Single Married, no children Married, with children
26 26 27 15
(22–30) (23–29) (24–30) (13–17)
48 36 32 32
(28–67) (29–42) (26–37) (26–37)
Socioeconomic status Manual worker Routine non-manual Semi-professional Professional Manager
38 26 18 13 14
(34–42) (25–28) (16–21) (11–15) (11–18)
35 42 24 27 16
(30–40) (34–50) (19–30) (22–32) (17–21)
Household income Lowest quartile Second quartile Third quartile Highest quartile
29 23 22 17
(27–32) (20–25) (19–24) (15–19)
39 29 24 23
(33–44) (24–34) (19–29) (17–28)
Education Basic Secondary Highest
31 (29–33) 20 (18–22) 13 (11–15)
37 (32–41) 25 (20–29) 23 (19–27)
Housing tenure Renter (from the employer) Renter (free market) Other Owner occupied
37 33 20 16
50 45 34 20
Social relations Daily Weekly Seldom
26 (23–29) 22 (20–24) 21 (19–23)
(34–40) (28–37) (15–25) (15–18)
(43–57) (36–53) (23–45) (18–23)
34 (27–40) 28 (24–32) 26 (22–31)
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Married mothers smoked less often than those living in other family types. However, there were no differences between other family types. Smoking among lone fathers was exceptionally high, 48%, among married fathers the corresponding figure was 32%. A gradient was found in smoking by all socioeconomic status measures. The lower the status, the higher the prevalence of smoking regardless of whether the measure of socioeconomic status was occupation, education or household income. An exception was routine non-manual men who smoked as often as manual men. It should also be noticed that manual women smoked as often as manual men. Also among managers there were no gender differences in smoking. Smoking was most prevalent among renters, a third (33–37%) of female renters and a half (45–50%) of male renters smoked. There were no differences between those who were free-market renters or renters from the employer (City of Helsinki). Smoking was least prevalent among women (16%) and men (20%) living in owner-occupied housing. Those who met their relatives or friends daily were more likely to be smokers than those who met their relatives and friends less often. Logistic regression analysis was used to study whether the other factors explained the associations of economic difficulties and household type with smoking. In the first model economic difficulties and household type were included separately. Among those who reported very many economic difficulties, and among lone parents, smoking was clearly higher than in the reference categories. In the second stage, economic difficulties and household type were included simultaneously. The association between smoking and economic difficulties remained stable, whereas the association between smoking and lone parenthood attenuated but remained strong
(Tables 2 and 3). In the following model education, occupational social class and income were included. The association between smoking and economic difficulties as well as the association between smoking and lone parenthood weakened but remained statistically significant. When housing tenure was included in the model among men, the associations between smoking and economic difficulties (OR ¼ 1.45) and between smoking and lone parenthood (OR ¼ 1.79) were no longer statistically significant (Table 3) but there were only 34 lone fathers in our data. Also the association between smoking and other types of household disappeared among men. Finally, after including social relations in the model both associations became stronger. All pairwise interactions between the study variables were checked. An interaction between family type and social relations was observed (for women p ¼ 0:04; for men p ¼ 0:003). The interaction showed that the association between smoking and family type existed only among mothers (both lone parents and the married) but not among the single or women living with a partner only. Women without children were not frequent smokers even if they had frequent social relations. In men, the interaction between family type and social relations was not consistent.
Discussion In this study we sought to examine whether there is an independent association between smoking and economic difficulties and between smoking and lone parenthood. We focused on the relatively better-off: middle-aged women and men who were employed and lived in Helsinki, the capital of Finland.
Table 2 Logistic regression analyses of the association between smoking and social background among women, age-adjusted odds ratios (OR) and 95% CI Women
Economic difficulties Too many Many Some Not at all Household type Lone parent Single Married, no children Married, with children
Economic difficulties and household type
Economic difficulties or household type
+Socioeconomic status (education, occupation, income)
+Housing tenure
+Social relations
2.88 (2.29–3.63) 1.63 (1.31–2.04) 1.47 (1.23–1.75) 1.00
2.81 (2.22–3.56) 1.60 (1.28–2.00) 1.45 (1.21–1.73) 1.00
2.23 (1.74–2.86) 1.35 (1.07–1.70) 1.29 (1.07–1.55) 1.00
1.88 (1.46–2.43) 1.22 (0.97–1.54) 1.21 (1.00–1.45) 1.00
2.28 (1.78–2.93) 1.39 (1.10–1.75) 1.32 (1.10–1.59) 1.00
2.23 (1.72–2.88) 1.88 (1.50–2.34) 1.80 (1.47–2.21) 1.00
1.83 (1.40–2.38) 1.82 (1.45–2.27) 1.91 (1.55–2.35) 1.00
1.74 (1.33–2.28) 1.84 (1.45–2.35) 1.79 (1.44–2.23) 1.00
1.47 (1.11–1.94) 1.58 (1.24–2.03) 1.66 (1.32–2.07) 1.00
1.71 (1.30–2.24) 1.77 (1.39–2.25) 1.81 (1.45–2.26) 1.00
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Table 3 Logistic regression analyses of the association between smoking and social background among men, age-adjusted odds ratios (OR) and 95% CI Men
Economic difficulties Too many Many Some Not at all Household type Lone parent Single Married, no children Married, with children
Economic difficulties and household type
Economic difficulties or household type
+Socioeconomic status (education, occupation, income)
+Housing tenure
+Social relations
2.69 (1.66–4.37) 1.60 (1.09–2.35) 1.27 (0.92–1.76) 1.00
2.44 (1.49–4.01) 1.57 (1.06–2.32) 1.31 (0.95–1.82) 1
1.86 (1.10–3.12) 1.27 (0.85–1.90) 1.12 (0.80–1.57) 1.00
1.45 (0.85–2.48) 1.08 (0.71–1.64) 1.06 (0.75–1.49) 1.00
1.89 (1.12–3.17) 1.28 (0.86–1.92) 1.13 (0.80–1.58) 1.00
3.65 (1.65–8.10) 1.73 (1.18–2.54) 1.38 (0.98–1.94) 1.00
2.98 (1.32–6.73) 1.68 (1.14–2.48) 1.41 (1.00–2.00) 1.00
2.39 (1.04–5.48) 1.56 (1.04–2.34) 1.35 (0.94–1.94) 1.00
1.79 (0.75–4.24) 1.03 (0.67–1.59) 1.27 (0.88–1.84) 1.00
2.34 (1.02–5.40) 1.49 (0.99–2.24) 1.36 (0.95–1.94) 1.00
The first result of our study was that smoking was clearly more common among lone parents than among married parents, even after adjusting for economic difficulties, socioeconomic status and social relations. Smoking was exceptionally high among lone fathers (48%). Lone fathers have been neglected in health research probably because their numbers are quite low. Our results differ from those found in the UK where smoking was not more common among lone fathers than their married counterparts (Jarvis & Wardle, 1999). Another important result of our study was that women and men having too many economic difficulties smoked twice as often as men and women having no economic difficulties, even when differences in socioeconomic status, household type and social relations were taken into account. We expected this association to disappear when income was adjusted for, but income explained among women only about one-fifth and among men about a half of the relationship between smoking and economic difficulties and the association between economic difficulties and smoking remained statistically significant. Housing tenure explained more than income (59% among men, 42% among women) but even after adjusting for several indicators of socioeconomic status and social relations the association between smoking and lone parenthood as well as smoking and economic difficulties remained. Economic difficulties are common in lone-parent households (Dorsett, 1999; OECD, 2001). Contrary to our expectation, adjusting for economic difficulties did not level off the association between smoking and lone parenthood. Thus, the third important finding in our study was that lone parenthood and economic difficulties are independently related to smoking. This held true for both women and men.
It should be noticed that we did not examine the most disadvantaged people, since all respondents were employed and lived in the capital area. Further, the respondents cannot be considered socially disadvantaged as most of them met their friends and relatives often. Our data were cross-sectional, thus no conclusions should be interpreted from causal relationships. It is possible that smoking and economic difficulties affect each other (Shiapush, Borland, & Scollo, 2003). Smoking in Finland is so expensive (one package of 20 cigarettes cost about 4 Euros) that it can significantly affect the money spent for basic necessities even among employed population. Economic difficulties may also cause additional stress that induce smoking. However, it is not very plausible that smoking affects lone parenthood. Our study showed that smoking is associated with social relations. Social networks seem to encourage smoking so that particularly among lone parents smoking seems to be an important part of social life. Thus, even though social relations are generally considered positive to health, in some contexts they might also include negative consequences. In some subcultures, smoking is considered positive and there may even be a normative pressure to smoke (Stead, MacAskill, MacKintosh, Reece, & Eadie, 2001). Such subcultures may be quite resistant to anti-smoking health promotion. The association between smoking and economic difficulties and lone parenthood shows that smoking is related to welfare deficits also among the employed population. Smoking seems to play a part in the accumulation of deprivation so that those who have economic difficulties also have a higher risk of poor health due to smoking. A Scottish in-depth interview
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study reported that many smokers from a disadvantaged area wanted to quit, but they emphasised the stressfulness of their lives and an addiction to smoking that hampered quitting (Wiltshire, Bancroft, Amos, & Parry, 2001). To facilitate smoking cessation, the interventions certainly should tackle the material circumstances of disadvantaged smokers (Lawlor, Frankel, Shaw, Ebrahim, & Davey Smith, 2003) as well as with nicotine addiction, but also with specific interventions on subcultures and social networks where smoking is acceptable and supported.
Acknowledgements The Helsinki Health Study is supported by the Academy of Finland (#45664, #48118 and #53245), and the Finnish Work Environment Fund (#99090). We thank all participating employees of the City of Helsinki and members of the Helsinki Health Study group.
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