Impact of the 1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by socioeconomic status
Introduction
Many health determinants, like smoking, differ across socioeconomic groups, leading to major disparities in morbidity and mortality (Mackenbach et al., 1997) (Macintyre, 1997). At the population level smoking behavior can be characterized as a four-stage process (Lopez et al., 1994, Lopez, 1995, Cavelaars et al., 2000). Initially, smoking tends to rise among high socioeconomic groups. During the middle stages of the process it spreads throughout the rest of the population. In stage three male smoking is most prevalent. Then, however, it starts to decrease due to cessation, especially in the highest socioeconomic groups. In female smoking the peak follows a few years later than in male smoking. In the last stage of the process smoking declines slowly in both genders but remains high among lower socioeconomic groups. This pattern of change in smoking has been compared to the general model of diffusion of innovations and adoption and rejection of fashions (Rogers, 1995, Pampel, 2005). It appears that almost all Northern European countries were at the final stage of the spread of smoking by the late 1980s or early 1990s. Finland also seems to have reached the end of the third stage by the early 1990s (Cavelaars et al., 2000) and was still there at the beginning of this decade (Giskes et al., 2005).
Smoking initiation and therefore ever smoking are influenced by various tobacco control policy measures such as anti-smoking campaigns (Vartiainen et al., 1998), special taxes on tobacco (Pekurinen and Valtonen, 1987, Townsend et al., 1994, Jha et al., 1999) and legislative norms (Helakorpi et al., 2004, Jha et al., 1999). There have been two major steps in Finnish tobacco control policy: the Tobacco Control Act of 1976 (TCA), supplemented by a total tobacco advertising ban in 1978, and the environmental tobacco smoke amendment of the TCA in 1995. The 1976 TCA prohibited smoking in most public places, including public transport, and the sale of tobacco products to those below 16 years of age and required obligatory health warnings on packages; part of the tobacco tax revenue was allocated for health education and tobacco related research purposes (Finlex, 2007, Leppo and Vertio, 1986, Puska et al., 1997, Leppo and Puska, 2003). Tobacco prices rose substantially (real price increase 27%) in 1975–1976, but since then annual increases have been either modest or negligible (Pekurinen and Valtonen, 1987). The 1976 TCA successfully reduced smoking initiation in cohorts around the age of initiation when it came into force (Helakorpi et al., 2004).
In our earlier study (Helakorpi et al., 2004), the impact of the 1976 TCA was assessed by examining the differences between birth cohorts in the prevalence of ever daily smoking. This is assumed to reflect the circumstances prevailing during the adolescent years of the cohort most critical as regards the risk of taking up regular smoking. The purpose of this study was to assess how Finnish anti-smoking legislation has impacted ever daily smoking across socioeconomic groups.
Section snippets
Materials and methods
The National Public Health Institute has conducted annual nationwide cross-sectional surveys since 1978 (Health Behaviour among Finnish Adult Population surveys) (Helakorpi et al., 2002). Each year an independent random sample (n = 5000) of the population aged 15–64 years has been drawn from the National Population Register. The questionnaire, with one reminder in 1978–1985, with two reminders in 1986–1997 and from 1998 onwards with three reminders, has stayed essentially the same over the years.
Variables examined
The variation in prevalence of ever daily smoking by birth cohort and socioeconomic group was examined separately by gender. Ever daily smoking was defined as a dichotomous variable and the inclusion criterion was having ever smoked daily for at least a year. Socioeconomic classification is based on the person's stage in life (family member, student, economically active, pensioner, etc.) and occupation and status in employment (self-employed, employee, unpaid family worker) for economically
Statistical methods
Logistic regression analysis was used to assess the contributions of birth cohort and the 1976 Tobacco Control Act to ever daily smoking separately in the five socioeconomic groups. The cohort (birth year) was included in the models to show the secular cohort trends of ever daily smoking. The possible change in the cohort trend after the TCA was examined in an analysis comprising the socioeconomic groups simultaneously. Furthermore, we added terms of the effect of the TCA piecewise by dividing
Results
Differences between socioeconomic groups in ever daily smoking in secular cohort trends and in the impact of the 1976 Tobacco Control Act are given in Table 2. Among men the secular cohort trend in smoking declined only in upper white collar workers, whereas in other socioeconomic groups the secular cohort trend was non-significant. A clear decline in the prevalence of male ever daily smokers concurrent with the TCA was found in all socioeconomic groups except farmers. The differences between
Discussion
Marked socioeconomic differences in ever daily smoking between birth cohorts were found for the study period 1978–2002. As presented earlier (Martelin, 1984, Laaksonen et al., 1999) smoking has been more common among Finnish men with low education and among manual workers in every male cohort born after 1921. In the oldest female birth cohorts smoking was more common among the higher educated and non-manual workers, whereas among women born in the late 1930s or later a reversal of these
Conclusion
Our results suggest that socioeconomic differences should be targeted more than before in the Finnish tobacco control policy.
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