Since Taiwan government opened the market of tobacco and alcohol to foreign companies in 1987, the society has experienced rises in alcohol use for both men and women. The prevalent rate of male smoking slightly decreased after 1990; however, the prevalent rate of female smoking is increasing [52
]. In the last two decades, rapid socio-economic change, such as massive movement of women into the paid work force, alters the role of women in Taiwan [6
]. This may result in an increasing use of cigarettes among women. This trend was also reflected in the marketing strategies used by the tobacco companies, in which images of masculine were used in tobacco promotion targeted for the male market, while liberation, glamour, and elite were used for the female market [53
]. Under this context, this study intends to understand how neighborhood-level factors contribute to the increases of individual smoking and drinking.
Our findings are partly consistent with prior studies that have assessed the associations between neighborhood-level characteristics and individual smoking. Similar to prior studies, we found that higher neighborhood social disorganization was directly associated with higher probability of smoking for women. As documented in Wilson's book The Truly Disadvantaged (1987), lower SES neighborhoods where local basic organizations collapse, conventional norms cannot be maintained, high rates of single-parent families are persistent, and high proportions of extremely poor people are isolated from the job network system may increase the likelihood of criminal behaviors and various types of substance abuse. Our study demonstrates that this is the case in Taiwan. Neighborhoods that featured higher rates of single parent families, unemployment, and divorced and separated individuals may have higher rates of female smoking.
Several cross-level interactions were discovered in multilevel analyses. In general, neighborhood characteristics had stronger effects on low SES individuals than on high SES individuals. Low SES individuals may have been more sensitive to local environments as they may have been less knowledgeable about the harmful effects of substance abuse, may have had fewer resources to stop smoking and drinking, and may have experienced more stressors in their daily lives than high SES individuals. We proposed two possible hypotheses, "relative deprivation" and "double jeopardy theory", to explain the interaction between neighborhood environments and individual SES. Our results indicate that different neighborhood dimensions may lead to different interaction patterns. For example, neighborhood education had a positive effect on smoking for low SES women, in contrast to a negative effect on smoking for high SES women. This result supports the hypothesis of "relative deprivation," suggesting that the less educated and less affluent may experience greater levels of stress and anxiety and sharper competition for scarce institutional resources (i.e., access to health care facilities) when competing with better educated, more affluent neighbors. Smoking may be a coping response to stressful neighborhood environments. On the other hand, neighborhood social disorganization seems to have increased effects on drinking behaviors for low SES individuals, but not for high SES individuals. These interactive effects support the hypothesis of the double jeopardy theory, suggesting that living in neighborhoods with high social disorganization will intensify the effects of individual low SES.
Contrary to the findings of previous studies, we found that living in neighborhoods with a higher percentage of elderly people was associated with lower likelihood of drinking for women. Concentration of elderly people was traditionally regarded as a disadvantaged neighborhood characteristic due to lack of community manpower and institutional resources. Most prior studies that examined the effect of concentration of elderly people focused on the outcomes other than smoking and drinking, such as self-rated health and mental health [55
]. We are not aware of any study investigating the effects of neighborhood concentration of elderly people on adult smoking and drinking behaviors.
In addition to the explanations of "double jeopardy" and "relative deprivation" hypotheses, the geographical distribution of neighborhoods may partially explain why low SES people in high educated and high social disorganized neighborhoods were more likely to smoke and drink. A large majority of high educated (70%) and high social disorganized (69%) neighborhoods locate in urban areas. Thus the culture of city life may influence one's opportunity to access cigarettes and alcohol. Social gatherings after work are more common in major cities in Taiwan. People relieve stress and renew personal bonds over a drink or by exchanging cigarettes. The provision of alcohol and cigarettes is a way of common courtesy. Low SES people may be more vulnerable to smoking and drinking culture in urban areas as they have fewer personal resources (i.e., knowledge about harmful effects of smoking) to reject smoking and drinking. Future research needs to clarify this relationship by using a better neighborhood geographical typology.
Our findings should be considered in light of the following limitations. First, we did not have longitudinal neighborhood measurements, which may generate selection bias [56
]. The relationship between neighborhood characteristics and smoking or drinking may be due to the non-random selection of individuals into neighborhoods and not because of neighborhood influences. Therefore, these relationships should be interpreted as associations only. Second, we did not measure the length of time that participants had spent in their neighborhoods and the extent of their exposure to the neighborhood environment. We were thus unable to determine whether effects of neighborhood characteristics on smoking and drinking behaviors were due to cumulated effects [56
]. Third, we did not measure all social and physical aspects of neighborhoods, such as informal social control, concentration of tobacco and alcohol outlets, and availability of social service agencies [47
]. Future research needs to improve neighborhood measurements by assessing multiple aspects of neighborhoods. Fourth, in contrast with most prior studies that measure the outcomes of problem drinking behaviors (i.e., binge drinking or drunk driving), our study identified drinkers if they had ever used alcohol. Because we do not have enough cases of problem drinking, we were unable to assess the neighborhood influences on problem drinking behaviors. Nevertheless, the way that we categorized alcohol use into "no use" and "at least some" can examine how neighborhood characteristics affect one's opportunities of exposure to any alcohol or one's decision to be a non-drinker. Fifth, we calculated the employment rate by the number of employed people divided by the population aged 15 over; however the employment rate should be calculated by the number of employed people divided by the size of labor force, which excludes housewives, students, disabled, and retired persons. Because the 2000 Taiwan census survey did not clarify the reasons why people were unemployed, we were not able to assess the impact of neighborhood employment rate on participants' behaviors. The impact of this inappropriate measurement may be limited, though, because the employment rate only contributes partially to the measurement of neighborhood social disorganization.