The creation of a smoking class: how prevention efforts can deepen social inequalities in health

"Die Verminderung sozialer Ungleichheit gehört in vielen Ländern zu den Kernzielen der Politik. Einzelne Elemente der Gesundheitspolitik können aber Folgen haben, die diesem allgemeinen Ziel entgegenwirken. Das zeigt das Beispiel der NichtraucherschutzPolitik. Das Rauchen wird sozial stigmatisiert, und den Rauchern, die in zunehmendem Maße aus den ärmeren Schichten kommen, wird abweichendes Sozialverhalten vorgeworfen. Dies führt zu einer Verschärfung gesellschaftlicher Trennungen, die eigentlich aufgehoben werden sollen."[Autorenreferat]"In many countries the reduction of social inequalities in health is an important policy goal. Some populationbased public health interventions, however, may have effects that in practise conflict with these objectives. Current antismoking policies, for instance, are framing smoking as a deviant, undesirable, and morally repugnant behaviour. The discourse embraced by tobacco control and public health may be contributing to the stigmatization of smokers, thus adding to the process of “lumpenization” of smoking and ultimately the social exclusion of economically disadvantaged smokers."[author´s abstract

The collective lifestyles framework : a contextual analysis of social practices, social structure and disease

Thèse diffusée initialement dans le cadre d'un projet pilote des Presses de l'Université de Montréal/Centre d'édition numérique UdeM (1997-2008) avec l'autorisation de l'auteur

Moving beyond the residential neighbourhood to explore social inequalities in exposure to area-level disadvantage: Results from the Interdisciplinary Study on Inequalities in Smoking

The focus, in place and health research, on a single, residential, context overlooks the fact that individuals are mobile and experience other settings in the course of their daily activities. Socioeconomic characteristics are associated with activity patterns, as well as with the quality of places where certain groups conduct activities, i.e. their non-residential activity space. Examining how measures of exposure to resources, and inequalities thereof, compare between residential and nonresidential contexts is required. Baseline data from 1,890 young adults (18 to 25 years-old) participating in the Interdisciplinary Study of Inequalities in Smoking, Montreal, Canada (2011- 2012), were analyzed. Socio-demographic and activity location data were collected using a validated, self-administered questionnaire. Area-level material deprivation was measured within 500-meter road-network buffer zones around participants’ residential and activity locations. Deprivation scores in the residential area and non-residential activity space were compared between social groups. Multivariate linear regression was used to estimate associations between individual- and area-level characteristics and non-residential activity space deprivation, and to explore whether these characteristics attenuated the education-deprivation association. Participants in low educational categories lived and conducted activities in more disadvantaged areas than university students/graduates. Educational inequalities in exposure to area-level deprivation were larger in the non-residential activity space than in the residential area for the least educated, but smaller for the intermediate group. Adjusting for selected covariates such as transportation resources and residential deprivation did not significantly attenuate the education-deprivation associations. Results support the existence of social isolation in residential areas and activity locations, whereby less educated individuals tend to be confined to more disadvantaged areas than their more educated counterparts. They also highlight the relevance of investigating both residential and non-residential contexts when studying inequalities in health-relevant exposures

Cultural capital and smoking in young adults: applying new indicators to explore social inequalities in health behaviour

Background: Associations between social status and health behaviours are well documented, but the mechanisms involved are less understood. Cultural capital theory may contribute to a better understanding by expanding the scope of inequality indicators to include individuals' knowledge, skills, beliefs and material goods to examine how these indicators impact individuals' health lifestyles. We explore the structure and applicability of a set of cultural capital indicators in the empirical exploration of smoking behaviour among young male adults. Methods: We analysed data from the Swiss Federal Survey of Adolescents (CH-X) 2010-11 panel of young Swiss males (n = 10 736). A set of nine theoretically relevant variables (including incorporated, institutionalized and objectified cultural capital) were investigated using exploratory factor analysis. Regression models were run to observe the association between factor scores and smoking outcomes. Outcome measures consisted of daily smoking status and the number of cigarettes smoked by daily smokers. Results: Cultural capital indicators aggregated in a three-factor solution representing ‘health values', ‘education and knowledge' and ‘family resources'. Each factor score predicted the smoking outcomes. In young males, scoring low on health values, education and knowledge and family resources was associated with a higher risk of being a daily smoker and of smoking more cigarettes daily. Conclusion: Cultural capital measures that include, but go beyond, educational attainment can improve prediction models of smoking in young male adults. New measures of cultural capital may thus contribute to our understanding of the social status-based resources that individuals can use towards health behaviour

Social inequalities in health information seeking among young adults in Montreal

Over their lifecourse, young adults develop different skills and preferences in relationship to the information sources they seek when having questions about health. Health information seeking behaviour (HISB) includes multiple, unequally accessed sources; yet most studies have focused on single sources and did not examine HISB’s association with social inequalities. This study explores ‘multiple-source’ profiles and their association with socioeconomic characteristics. We analyzed cross-sectional data from the Interdisciplinary Study of Inequalities in Smoking involving 2093 young adults recruited in Montreal, Canada, in 2011–2012. We used latent class analysis to create profiles based on responses to questions regarding whether participants sought health professionals, family, friends or the Internet when having questions about health. Using multinomial logistic regression, we examined the associations between profiles and economic, social and cultural capital indicators: financial difficulties and transportation means, friend satisfaction and network size, and individual, mother’s, and father’s education. Five profiles were found: ‘all sources’ (42%), ‘health professional centred’ (29%), ‘family only’ (14%), ‘Internet centred’ (14%) and ‘no sources’ (2%). Participants with a larger social network and higher friend satisfaction were more likely to be in the ‘all sources’ group. Participants who experienced financial difficulties and completed college/university were less likely to be in the ‘family only’ group; those whose mother had completed college/university were more likely to be in this group. Our findings point to the importance of considering multiple sources to study HISB, especially when the capacity to seek multiple sources is unequally distributed. Scholars should acknowledge HISB’s implications for health inequalities

Expected or completed? Comparing two measures of education and their relationship with social inequalities in health among young adults

Background. Similarly to other age groups, there are significant social inequalities in health among young adults (YA). Education is thought to be the most appropriate indicator of YA socioeconomic status (SES), yet it is often in progress at that age and may not be representative of future achievement. Therefore, scholars have explored YA ‘expected’ education as a proxy of SES. However, no study has examined how it compares to the more common SES indicator, ‘completed’ education. Methods. Using data from 1,457 YA surveyed twice over a two year period, we describe associations between participants’ completed and expected education at baseline and completed education at followup. We then compare associations between these two measures and three health outcomes – smoking status, self-rated mental health, and participation in physical activity and sports – at baseline and follow-up using regression models. Results. At baseline, half of the participants were imputed a higher ‘expected’ level than that ‘completed’ at that time. In regression models, ‘expected’ and ‘completed’ education were strongly associated with all outcomes and performed slightly differently in terms of effect size, statistical significance, and model fit. Conclusions. ‘Expected’ education offers a good approximation of future achievement. More importantly, ‘expected’ and ‘completed’ education variables can be conceptualized as complementary indicators associated with inequalities in health in YA. Using both may help better understand social inequalities in health in YA

The added value of accounting for activity space when examining the association between tobacco retailer availability and smoking among young adults

Background: Despite a declining prevalence in many countries, smoking rates remain consistently high among young adults. Targeting contextual influences on smoking, such as the availability of tobacco retailers, is one promising avenue of intervention. Most studies have focused on residential or school neighbourhoods without accounting for other settings where individuals spend time, i.e., their activity space. We investigated the association between tobacco retailer availability in the residential neighbourhood and in the activity space and smoking status. Methods: Cross-sectional baseline data from 1,994 young adults (age 18-25) participating in the Interdisciplinary Study of Inequalities in Smoking (Montreal, Canada, 2011-2012) were analyzed. Residential and activity locations served to derive two measures of tobacco retailer availability: counts within 500-meter buffers and proximity to the nearest retailer. Prevalence ratios for the association between each tobacco retailer measure and smoking status were estimated using log-binomial regression. Results: Participants encountering high numbers of tobacco retailers in their residential neighbourhood, and both medium and high retailer counts in their activity space, were more likely to smoke compared to those exposed to fewer retailers. While residential proximity was not associated with smoking, we found 36% and 42% higher smoking prevalences among participants conducting activities within medium and high proximity to tobacco retailers compared to those conducting activities further from such outlets. Conclusion: This study adds to the sparse literature on contextual correlates of smoking among young adults, and illustrates the added value of considering individuals’ activity space in contextual studies of smoking

Taking account of context in population health intervention research: guidance for producers, users and funders of research

Population health intervention research (PHIR) seeks to develop and evaluate policies, programmes and other types of interventions that may affect population health and health equity. Such interventions are strongly influenced by context – taken to refer to any feature of the circumstances in which an intervention is conceived, developed, implemented and evaluated. Understanding how interventions relate to context is critical to understanding how they work; why they sometimes fail; whether they can be successfully adapted, scaled up or translated from one context to another; why their impacts vary; and how far effects observed in one context can be generalised to others. Concerns that context has been neglected in research to develop and evaluate population health interventions have been expressed for at least 20 years. Over this period, an increasingly comprehensive body of guidance has been developed to help with the design, conduct, reporting and appraisal of PHIR. References to context have become more frequent in recent years, as interest has grown in complex and upstream interventions, systems thinking and realist approaches to evaluation, but there remains a lack of systematic guidance for producers, users and funders of PHIR on how context should be taken into account. This document draws together recent thinking and practical experience of addressing context within PHIR. It provides a broad, working definition of context and explains why and how context is important to PHIR. It identifies the dimensions of context that are likely to shape how interventions are conceptualised, the impacts that they have and how they can be implemented, translated and scaled up. It suggests how context should be taken into account throughout the PHIR process, from priority setting and intervention development to the design and conduct of evaluations and reporting, synthesis and knowledge exchange. It concludes by summarising the key messages for producers, users and funders of PHIR and suggesting priorities for future research. The document is meant to be used alongside existing guidance for the development, evaluation and reporting of population health interventions. We expect the guidance to evolve over time, as practice changes in the light of the guidance and experience accumulates on useful approaches. The work was funded by the Canadian Institutes of Health Research (www.cihr-irsc.gc.ca) – Institute of Population and Public Health (CIHR-IPPH) and the UK National Institute for Health Research (NIHR)