Prevalence rates of smoking increased from 31.6% in the most advantaged to 41.3% in the most disadvantaged quartile of neighbourhoods (table 1). The average amount of cigarettes smoked daily by current smokers varied between 15.5 and 16.5, and did not differ significantly between the quartiles of neighbourhood socioeconomic environment. Smokers in the most disadvantaged neighbourhoods started smoking significantly earlier in their lives compared with smokers in the most advantaged neighbourhoods (mean ages being 17.3 years and 18.2 years, respectively).
Table 1Descriptive statistics by neighbourhood socioeconomic environment
Adjusted for age and sex, living in neighbourhoods with the worst compared with the best socioeconomic conditions was associated with an increased probability of smoking (odds ratio 1.68, 95% CI 1.42 to 1.98) (table 2). Additional adjustment for education, occupation, and employment status attenuated the odds ratio substantially, but the probability of smoking remained significantly increased in the most disadvantaged neighbourhoods (odds ratio 1.24, 95% CI 1.05 to 1.46). The educational gradient in smoking seemed to be larger than the gradient for the neighbourhood socioeconomic environment (odds ratio in the lowest compared with highest educational group 2.33, 95% CI 2.02 to 2.70). The gradient attenuated after adjustment for the neighbourhood socioeconomic environment, but remained steeper than at the neighbourhood level (odds ratio in the lowest educated group 1.96, 95% CI 1.65 to 2.33).
Table 2Odds ratios (and 95% confidence intervals) of smoking by neighbourhood socioeconomic environment and by education in men and women in the GLOBE study, the Netherlands, 1991
Adjusted for age and sex, living in the neighbourhoods with the highest stress score was associated with an increased probability of smoking (odds ratio 2.31, 95% CI 1.69 to 3.17, not tabulated). Additional adjustment for the individual level indicators of SEP attenuated the odds ratios, while further adjustment for the neighbourhood socioeconomic environment resulted in a modest attenuation. However, the odds ratio in the neighbourhoods with the highest stress score remained significantly increased (odds ratio 1.57, 95% CI 1.11 to 2.21).
Using separate characteristics of the stress scores showed no association between the quality of the physical living environment and the probability of smoking. Increased odds ratios of smoking were found for participants in neighbourhoods with increased police attention required and with a higher population density as compared with the neighbourhoods in the reference group. Adjustment for the neighbourhood socioeconomic environment attenuated odds ratios slightly, with only a significantly increased probability of smoking for those in the most densely populated neighbourhoods (odds ratio 1.28, 95% CI 1.00 to 1.46). Furthermore, the probability of smoking was higher in people living in the neighbourhoods with the highest noise pollution from traffic, even after adjustment for the neighbourhood socioeconomic environment (odds ratio 1.17, 95% CI 1.01 to 1.36). At the individual level, those who reported many financial problems were more likely to smoke as compared with those reporting no problems meeting ends financially and this association was independent of the neighbourhood socioeconomic environment (odds ratio 3.05, 95% CI 2.46 to 3.79).
For the factors related to smoking, the ecological relation with the neighbourhood socioeconomic environment was explored. Using a one way analysis of variance technique, the mean stress score significantly decreased with increasing neighbourhood socioeconomic environment (F
14.71, 3 df, p<0.00). An increasing neighbourhood socioeconomic disadvantage was associated with an increasing police attention required (r
0.50, p<0.001), a larger population density (r
0.56, p<0.001), and an increasing percentage of participants reporting many problems meeting ends financially in neighbourhoods (r
0.58, p<0.001). There seemed to be however, no association with noise pollution from traffic (r
Adjusting the association between the neighbourhood environment and smoking for the neighbourhood stress score resulted in a substantial reduction of the odds ratios, which were no longer statistically significant (table 4). Adjusting the same association for the required police attention and for the population density separately showed that both characteristics contributed about equally large to the neighbourhood socioeconomic inequalities in smoking. Adjusting the association for problems with meeting ends financially affected the odds ratios of smoking by the neighbourhood socioeconomic environment only moderately. The educational inequalities attenuated moderately after adjustment for the neighbourhood stress score, or the separate characteristics. Problems with meeting ends financially contributed more substantially to these inequalities.
Table 4Effect of adjusting the association of the neighbourhood socioeconomic environment and education with smoking by individual and neighbourhood characteristics in the GLOBE study, the Netherlands, 1991
What this paper adds
This paper adds to understanding neighbourhood variation in smoking. While scarce knowledge on this topic was thus far concentrated on differential exposure to advertisements and tobacco availability, this study showed that physical stressors from the neighbourhood—often beyond control of the person—are related to smoking. As far as to our knowledge, it is the first international paper showing that “objectively” measured neighbourhood stressors mediate neighbourhood and individual socioeconomic inequalities in smoking.
Finally, interaction effects were found between the neighbourhood socioeconomic environment and education. Stratified analyses by individual educational level showed that the probability of smoking for participants in more compared with the least disadvantaged neighbourhoods was highest for the lowest educated participants (fig 1). The odds ratio for the lowest educated persons residing in the most compared with the least disadvantaged neighbourhoods was 1.86 (95% CI 1.18 to 2.93). Adjustment for problems with meeting ends financially did not mediate this association (odds ratio
1.84, 95% CI 1.16 to 2.92) but required police attention and population density did to some extent (odds ratio
1.76, 95% CI 1.07 to 2.89).
Figure 1Odds ratios (and 95% confidence intervals) of smoking by neighbourhood socioeconomic environment in the GLOBE study, the Netherlands, 1991, stratified by education.