Elsevier

Health & Place

Volume 7, Issue 4, December 2001, Pages 333-343
Health & Place

“It's as if you’re locked in”: qualitative explanations for area effects on smoking in disadvantaged communities

https://doi.org/10.1016/S1353-8292(01)00025-9Get rights and content

Abstract

Evidence suggests that place of residence may be associated with smoking independently of individual poverty and socio-economic status. Qualitative research undertaken in disadvantaged communities in Glasgow explored possible pathways which might explain this ‘area effect’. A poorly resourced and stressful environment, strong community norms, isolation from wider social norms, and limited opportunities for respite and recreation appear to combine not only to foster smoking but also to discourage or undermine cessation. Even the more positive aspects of life, such as support networks and identity, seem to encourage rather than challenge smoking. Policy and intervention responses need to tackle not only individual but also environmental disadvantage.

Introduction

There is an increasing amount of evidence to suggest that residence in a disadvantaged area may have an effect on risk of illhealth independently of variables such as socio-economic status, income and education (e. g. Yen and Kaplan, 1999; Smith et al., 1998; Haan et al., 1987; Whitley et al., 1999). Several factors may explain this apparent effect. Firstly, disadvantaged communities are often poorer in the facilities and services which are necessary or beneficial to health, as a result of sub-standard housing, poor planning, and underinvestment (SEU, 1998; JRF, 1999). Secondly, living in a disadvantaged community means worsened job prospects, which in turn increases risks to physical and psychological health (Wadsworth et al., 1999; Linn et al., 1985). Employers are reluctant to consider people from ‘bad areas’ (e.g. SEU, 1998), it is harder for people from such areas to find work because they are less likely to know people in employment (e.g. Atkinson and Kintrea, 2000; Russell, 1999; Morris, 1992), and if they do find employment are likely to face greater transport and childcare difficulties (Ong and Blumenberg, 1998; SEU, 1998). Thirdly, living in a disadvantaged area tends to bring increased exposure to stresses produced by higher levels of crime, violence, and incivilities such as littering and vandalism.

Fourthly, disadvantaged communities provide fewer opportunities for social interaction and participation. High levels of unemployment and a paucity of basic amenities mean that there are fewer places and settings in which people can meet (e.g. JRF, 1999). That social contact can have beneficial effects on health has been suggested in a number of studies (e.g. Veenstra, 2000; Wilkinson, 1996; Putnam, 1995; Cooper et al., 1999). Finally, it is suggested that residence in a disadvantaged community can lead to feelings of exclusion, stigmatisation, segregation and abandonment (e.g. JRF, 1999), all of which may affect mental health. Kawachi and Kennedy (1999) suggest that “invidious social comparisons”—feelings not only of absolute disadvantage but of the community's relative disadvantage in comparison with society as a whole—can have a “harmful psycho-social effect” (p. 215). Wilkinson (1996) argues that these feelings, combined with the deterioration in the physical environment, act as a constant reminder “of the atrophy of any sense of having a place in a community, and of one's social exclusion and devaluation as a human being” (p. 215).

It is systematically documented that while smoking has declined in the general population, it has not declined among the most disadvantaged (Marsh and McKay, 1994). Lower income groups are more likely both to smoke and not to have quit (Flint and Novotny, 1997), and consume disproportionately high amounts of tobacco (Whitlock et al., 1997). Explanations for the increased smoking in disadvantaged communities include: poverty (Flint and Novotny, 1997), economic insecurity (Graham, 1998), housing tenure (Marsh and McKay, 1994), education (Diez-Roux et al., 1999), isolation and the stress of caregiving (Stewart et al., 1996a; Graham, 1987), low self-efficacy (Stewart et al., 1996b), poorer psychological health (Graham and Der, 1999), targeting by the tobacco industry of low income and minority neighbourhoods (e.g. Hackbarth et al., 1995), and the lack of “optimism” which characterises these low income areas (Marsh and McKay, 1994).

Recent studies have suggested another factor in low income smoking: the ‘area effect’ of living in a disadvantaged neighbourhood. Kleinschmidt et al. (1995) analysed data on individual smoking from a regional health survey by neighbourhood deprivation scores for 1991 census wards in north west Thames, and found that a highly significant association existed between being a smoker and neighbourhood deprivation score of area of residence. This association remained even after the individual's socio-economic group status had been taken into account. A study (Reijneveld, 1998) of 5000 individuals in Amsterdam found that the higher prevalence of smoking in certain neighbourhoods could only be partly explained by the socio-economic status of residents, and suggested that residence in a deprived area contributed to higher smoking prevalence independently from low socio-economic status and other factors. Most recently, Duncan et al. (1999), in a multi-level analysis of British Health & Lifestyle Survey data, found ward-level differences in smoking behaviour which could not be explained by individual characteristics, population composition or ward-level deprivation.

Qualitative research conducted in disadvantaged areas in Scotland in 1998–99 explored possible explanations for this phenomenon. The study was interested particularly in the ways in which smoking might be fostered (and smoking cessation hindered) by residence in communities excluded economically, culturally and physically from mainstream society. The remainder of this paper describes the methods, results and conclusions from this study.

Section snippets

Methods

Qualitative focus group research was conducted with smokers and non-smokers in three Glasgow communities, as part of a larger 3-year Cancer Research Campaign investigation into the nature of smoking and the barriers to cessation in low income areas (CSM, 1998 (1998), CSM, 1998 (2000); Jackson and MacFadyen, 1998; MacAskill et al., 1999; Reece et al., 2000). The full study is being conducted in eight communities in Glasgow identified as having the highest levels of deprivation (DEPCAT score

Results

Some of the most common themes emerging from the groups are explored below. These potentially provide qualitative explanations for the pathways by which residence in a disadvantaged area is associated with higher levels of smoking. Where differences in feelings and experiences were apparent between sub-groups (e.g. men and women, older and younger respondents), these are indicated.

Discussion

A number of recent quantitative studies have suggested that residence in a disadvantaged community may have an independent effect on smoking over and above the effects of individual disadvantage (e.g. Kleinschmidt et al., 1995; Reijneveld, 1998; Duncan et al., 1999; Ellaway and Macintyre, 1996). However, there remains a need for research to identify the specific “features of places” (Ecob and Macintyre, 2000), particularly of disadvantaged communities, which might account for this. Our

Conclusions

In conclusion, the study has relevance for the wider policy debate concerning smoking and disadvantage. Increasingly, health promotion interventions are recognising that the many competing pressures on people in disadvantaged communities mean that stopping smoking is for many not a high priority—an argument supported by data from our quantitative survey showing that the majority of smokers in disadvantaged communities in Glasgow are in the ‘pre-contemplation’ stage. Interventions which are

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