Results

In women the prevalence of smokers was higher in social class I (29.8%) and decreased until social class V (18%). The adjusted odds ratio (OR) for social class V in reference to social class I was 0.36 (95%CI: 0.19, 0.67). The opposite occurred among men, where the classes IV and V smoked more (table 2). These results were also reflected in the multivariate analyses adjusted for age, employment status and family structure, even though among men the association lost statistical significance (table 3). Smoking cessation was greater among men in the higher classes, OR for classes IV and V were less than 1 and statistically significant; in women no clear trends were observed (table 3).

Among women light and excessive alcohol consumption were greater in classes I and II, with ORs becoming progressively smaller and further from 1. Among men light alcohol consumption was more important in upper classes (61% of class I and 45% of class V, OR=0.57, 95%CI:0.32, 1.00), while no differences were found in excessive alcohol consumption (tables 2 and 3).

Less than 5% of men and women in class I declared that they usually performed intense physical activity in contrast with 11.5% of men and 8.6% of women in class V (table 2), an association that persisted in the multivariate analysis, the ORs for the lower classes being greater than 2 (table 3). People of social classes I and II were more likely to engage in usual physical activity classified as “light or none” than lower social classes (table 3). For leisure time physical activity the situation is reversed, particularly in men, as a greater proportion of the lower classes did not engage in physical activity three or more times per week (74% of men in class I and 79% in class V). In the multivariate analysis the association was not statistically significant (OR for class V: 1.25, 95% CI: 0.61, 2.57). In women there was no clear trend (tables 2 and 3).

Table 4 depicts the number of reported health risk behaviours according to social class. Women of higher classes were engaged in two or more health risk behaviours more frequently and it was statistically significant in multivariate analysis (OR for class V: 0.33, 95%CI: 0.18, 0.62) (table 3). In men the situation is reversed, although it was not statistically significant in multivariate analysis (tables 3and 4).

Discussion

This is one of the first studies on social inequalities in health related behaviours in a southern European city. Overall, it has shown that the patterns of tobacco consumption according to social class are different for men and women. In this regard, a higher prevalence of smokers was found among women of higher class. The opposite is true in men although not statistically significant. Smoking cessation was greater among men in the higher classes. Men and women of social class I and II were more likely to report light alcohol consumption. Excessive alcohol consumption among men showed no significant differences between classes; while among women the consumption was higher in the highest social classes. The lower class population, especially men, stated that they performed more usual physical activity and less leisure time physical activity (this was not statistically significant in multivariate analysis).

TOBACCO CONSUMPTION

In Spain tobacco is easily available and cheap, and its consumption has a high social acceptance.29 The highly addictive nature of tobacco products makes it very difficult to untangle the precise role of its social influences. For instance, it is clear that social pressure plays a key part in smoking adoption30; nevertheless when these influences disappear or are recognised, a powerful addiction has been established. At this new stage, social influences may still play an important part, reinforcing the behaviour and some of its cognitive determinants.31 The modern epidemic of smoking consumption, can be seen as an example of the diffusion in a given society of an “innovation”32 that would grow first among men, reaching its peak after 30–40 years. After this peak there would be a decrease, related to public awareness of the consequences of tobacco use, which would start to be visible after that time, especially regarding cancer. The epidemic among women would come later,33 34 and would not eventually reach the same peak, because of the “vicarious” effects of tobacco use seen in men.4 Therefore, the epidemic of smoking would reflect the importance of social influences, especially of social position, as those groups who were the first to smoke—because of the “social” prestige of the innovation—are a few decades afterwards the first to quit, because of awareness of its consequences. This hypothesis is supported by many studies in European35 and other developed countries like the United States, Australia and Canada that report a higher prevalence of smokers among lower social classes and among those with lower education levels.1 5 36 37 In contrast, in southern European countries, including Spain, the differences between social classes are not so marked among men; while women in higher classes smoke the most6 9 35 38 39although smoking among women of lower classes has been increasing in recent years.7 In addition, it is noteworthy that smoking cessation rate (percentage of ex-smokers in relation to the total number of smokers and ex-smokers) is higher in groups with highest levels of education and in upper social classes in developed countries.40 41 Our findings are consistent with this pattern, as we found higher rates of smoking cessation among upper social classes mainly in men.

ALCOHOL CONSUMPTION

Spain is among the top 10 countries of the world in the production of alcoholic beverages, particularly wine. Consumption of wine in small amounts has long been part of everyday meals and is socially accepted. In addition, initiation to alcoholic drinks usually takes place within the family, in the context of social events and family celebrations.42 Alcoholic beverages are cheap and widely available, which facilitates an increased consumption, although binge drinking (drinking fast for the sole purpose of getting drunk) is less common than in northern European countries.43 The most common pattern of consumption for the adult population is daily drinking, with the youngest population increasing their consumption at weekends.44 45 The type of beverage consumed is mainly wine, although the pattern is changing to beer.46 47

In this study, men of upper classes were lighter drinkers, while among women, the higher classes declared greater consumption (both light and heavy drinkers). In a study done in the UK it was found that the prevalence of heavy drinkers among men is higher among manual workers, while the higher classes had more light and non-drinkers. In the case of women it was always the higher classes who drank more.2 This pattern has also been reported for Spain by social class in men9 and by educational level in men and women.48 However, other studies have found no association between alcohol consumption and social class49or have found an association showing that people of higher social class drink more.50 One study in the north of Europe has detected a change in the excessive alcohol consumption by social class: in the 1960s or 1970s non-manual workers drank more, a pattern that reversed during the 1980s.51 To explain this pattern, a model of diffusion of new habits by social class or educational level has been used. New habits, in this case alcohol consumption, are initiated by upper social classes or by the more educated as it was in relation to tobacco consumption.32 Hupkenset al have described that people with higher education levels consume the new beverage type more often and in greater numbers compared with people of lower educational level. This pattern is maintained in both northern and southern European countries. These differences in the consumption of new alcoholic beverages indicate a diffusion of new habits initiated by the more educated people. Furthermore, differences in consumption between men and women are smaller among those with higher education levels than among those with lower, which could be explained because of the consumption of new beverages in higher education levels.52

PHYSICAL ACTIVITY

Leisure time physical activity is not one of the most important activities that Spanish people do in their spare time, although they consider that physical activity is important for good health and recreation and it is an easy activity.53 Nevertheless, a decrease has been recently observed in the proportion of people who are inactive in leisure time.9

The pattern of physical activity found among men in Barcelona, where people in higher classes undertake more leisure time physical activity (although not statistically significant), but less usual physical activity, has been previously described.3 54-56 In the UK it has been reported, using data from two health surveys, that higher classes perform more leisure time physical activity.1 2 Salonen et aldescribe how, in two Finnish cohorts participating in a health related project in North Karelia, education level was positively related with leisure time physical activity, and negatively with occupational physical activity.57 Ford et algive similar results using data from a telephone survey carried out in Pittsburgh to determine physical activity in higher and lower socioeconomic status populations.58

In fact, usual physical activity is mainly related to occupational physical activity among workers, and to activities of daily living among people that do not have a paid employment (for example, houseworkers). Hence it is reasonable to expect that persons in lower social classes perform more intense physical activity as this is implicit in their occupations.59 Even so, it should be pointed out that the proportions of people performing intense physical activity are relatively low in all social classes, because in industrialised societies jobs require less and less physical activity. As a result, physical activity is becoming more and more part of leisure time.60

LIMITATIONS AND CONCLUSION

The possible limitations of information as declared in a health interview survey should be mentioned. The validity of declarations about alcohol consumption is unknown, although there are some reports suggesting that consumption is usually under-declared.43 61 In fact the potential biases affecting this study would arise if the declarations were differential depending on social class, something that has not been studied in this country. We do not, however, have any evidence that supports this hypothesis.

Social class was derived from current or last occupation of the interviewed, although 44% of women and 22% of men were classified with the occupation of the head of the household (housewives, unemployed, students, etc). In this regard it should be mentioned that the results were very similar when all people had assigned the social class of the head of the household.

It is also necessary to mention that the sample size was insufficient to find statistically significant associations in some cases (for example leisure time physical activity in men), but standardised percentages and OR indicate the main trends.

This study found that the group whose health related behaviours imply greatest risk is lower class men. Women in more disadvantaged social situations smoke less and drink less alcohol. These results suggest that health policies should take into account these patterns.