In response to the severe economic collapse in Iceland, we found that the prevalence of smoking continued to decrease for both genders in the short period after. This drop in smoking may be attributed to background secular trends,21
while other factors, such as changes in the price of cigarettes, and changing norms about the acceptability of smoking, may also have played a role. The strength of our study is that we were able to document changes in individual economic status straddling the economic downturn and link these exposures to individual changes in smoking habits. Additionally, in comparison to national smoking rates (2007: 23.0% of population; 2009: 19.0%) the prevalence rates from 2007 to 2009 of this sample are relatively analogous—offering support for the generalisability of the sample.
Our findings partially corroborate previous research on the procyclical nature of the association between economic downturns and smoking habit, that is, during recessions, smoking habits may be dampened. Among male former smokers, those who experienced a decline in income during the economic recession had a significantly lower risk of relapse two years later. Conversely, among men whose incomes increased during the period of recession, their risk of relapse was considerably higher compared to those whose incomes stayed the same. Although the direction of associations was similar among women, none of the estimates were statistically significant.
Taken together, the main significant finding of our analyses is that male former smokers whose incomes fell during the period of the economic collapse experienced a reduced risk of relapse. Ruhm22
hypothesised that this risk reduction is possibly driven by a tendency to adopt healthier behaviours during periods of reduced income—driven by an increase in positive health behaviours (ie, exercise) that accompanies newly acquired increased leisure time during economic contractions. It could also be argued their behaviour change in a recession can be either intentional or inadvertent. When facing enforced economic inactivity—individuals may choose to fill their time by actively investing in positive personal health changes, which include stopping smoking or joining a fitness club. However, our results did not indicate an increased risk of quitting among those whose incomes fell—which is inconsistent with previous research by Siahpush and Carlin.23
It is possible that smoking cessation and smoking relapse are ‘asymmetric’ behaviours with different triggers. Thus, a former smoker who experiences a drop in income may be less tempted to start smoking again because of the reduced affordability of cigarettes. However, someone who is already smoking may be less sensitive to an income drop (higher income inelasticity)—that is, he is unable to quit his ongoing behavior because of the offsetting increase in stress (although our data on self-reported stress did not support this).
There is an apparent discrepancy between the national decline in smoking in Iceland and the fact that smokers whose incomes declined were not more likely to quit. This underscores the point that macrolevel data and individual-level patterns are often driven by a different set of causes. Thus, the overall decline in national smoking rates could be either due to the procyclical nature of smoking (ie, recessions are good for health), or it may simply reflect a continuation of trends already in place prior to the recession (ie, national antismoking campaigns, declining social acceptability of smoking, etc). In other words, national averages are driven by more than the group of smokers whose incomes decreased after the crisis.
Furthermore, we caution that our findings regarding recession, income change and smoking habits cannot be generalised to other health outcomes. For example, observational reports found a spike in female cardiac emergency visits during the week corresponding to the economic collapse in October 2008.3
In accordance with this, our previous analysis on changes in mental health revealed significant increases in stress for mainly women.4
This increase in stress for women, however, threatening to related health outcomes, did not prove to be associated with an increased likelihood of relapsing.
Our findings are also congruent with multiple models explaining the link between stress levels and smoking behaviour. Though much research shows stress as a cause of smoking,15
additional research actually points to cigarette smoking as a cause of stress and, furthermore, smoking cessation as leading to a reduction in stress.20
This is in line with our findings, as both male and female relapsed smokers had the lowest levels of stress before the collapse when they considered themselves as having quit smoking in 2007 (), yet experienced an increase in stress postcollapse—significantly for women. This may also point to a vulnerability of this group to use smoking as a means of alleviating stress—explaining their relapse in smoking after the collapse.24
This vulnerability has been discussed and supported by previous research showing economic stress as a cause of adverse mental health.25
This increased stress may have also been amplified by a return to smoking, as Cohen and Lichtenstein26
have found. Caution is warranted in interpreting the findings on stress, however, since smokers may be citing an increase in perceived stress to justify their relapse or failure to quit. We cannot conclusively argue that stress did not play a mediating role in the association between income change and smoking behaviour because of measurement error.
Some limitations of our study should be noted. Relapsed smokers and quitters represent a small proportion of the population, and hence our ORs were estimated with imprecision and must be interpreted with caution. Similarly, we lacked statistical power to directly examine the effects of a change in employment status on change in smoking habits. In other words, though we were able to examine the effects of income change, we were not able to directly estimate the effects of unemployment as there were too few individuals in the sample who lost their jobs between 2007 and 2009. While our findings are based on the potential effects of an economic crisis on a change in smoking status, it is not clear whether these similar findings would hold true in normal scenarios and, thus, caution is warranted when generalising our findings to other normative scenarios. Finally, smoking status was based on self-report only, and not validated by biomarkers such as cotinine. This may have produced misclassification of the outcome, though it is not clear whether this misclassification was differential by exposure status (eg, income changes).
Our large population-based cohort with assessment points straddling the 2008 economic crisis in Iceland revealed a reduction in smoking rates from the short periods before and after the start of the crisis—though our study could not disentangle the direct effects of the crisis with other mechanisms, for example, secular trends and changing cigarette prices. Chiefly, this examination revealed a role of income change on the risk of relapse after the collapse among former male smokers.