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Economic Crisis and Smoking Behaviour: Prospective Cohort Study in Iceland Economic crisis and smoking behaviour: prospective cohort study in Iceland The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation McClure, Christopher Bruce, Unnur A Valdimarsdóttir, Arna Hauksdóttir, and Ichiro Kawachi. 2012. Economic crisis and smoking behaviour: prospective cohort study in Iceland. BMJ Open 2(5): e001386. Published Version doi:10.1136/bmjopen-2012-001386 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:10579571 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Open Access Research Economic crisis and smoking behaviour: prospective cohort study in Iceland Christopher Bruce McClure,1,3 Unnur A Valdimarsdóttir,1 Arna Hauksdóttir,1 Ichiro Kawachi2 To cite: McClure CB, ABSTRACT ARTICLE SUMMARY Valdimarsdóttir UA, Objective: To examine the associations between the Hauksdóttir A, et al. 2008 economic collapse in Iceland and smoking Economic crisis and smoking Article focus behaviour at the national and individual levels. behaviour: prospective cohort ▪ An examination on the association between eco- study in Iceland. BMJ Open Design: A population-based, prospective cohort study nomic crises and smoking behaviours, that is, is 2012;2:e001386. based on a mail survey (Health and Wellbeing in change in income (at both the national and indi- doi:10.1136/bmjopen-2012- Iceland) assessed in 2007 and 2009. vidual levels) related to a change in smoking 001386 Setting: National mail survey. status? Participants: Representative cohort (n=3755) of Key messages ▸ Prepublication history and Icelandic adults. ▪ National smoking prevalence declined in Iceland additional material for this Main outcome measure: Smoking status. paper are available online. To following the 2008 economic crisis. Results: A significant reduction in the prevalence of ▪ In individual-level analysis, male former smokers view these files please visit smoking was observed from 2007 (pre-economic the journal online whose incomes declined experienced a reduced collapse) to 2009 (postcollapse) in both males (http://dx.doi.org/10.1136/ risk of smoking relapse. – – bmjopen-2012-001386). (17.4 14.8%; p 0.01) and females (20.0 17.5%; p ▪ Conversely, an increase in income from 2007 to 0.01) in the cohort (n=3755). At the individual level of 2009 was associated with increased risk of Received 26 April 2012 analysis, male former smokers experiencing a relapse. Accepted 6 September 2012 reduction in income during the same period were less ▪ Our findings are consistent with the hypothesis likely to relapse (OR 0.37; 95% CI 0.16 to 0.85). This final article is available that economic downturns may result in Female smokers were less likely to quit over time decreased tobacco use (procyclical effect). for use under the terms of compared to males (OR 0.65; 95% CI 0.45 to 0.93). the Creative Commons Among male former smokers who experienced an Strengths and limitations of this study Attribution Non-Commercial increase in income between 2007 and 2009, we ▪ 2.0 Licence; see A representative prospective cohort study http://bmjopen.bmj.com observed an elevated risk of smoking relapse assessed at two time points, which straddle the (OR 4.02; 95% CI 1.15 to 14.00). start of a severe economic crisis. Conclusions: The national prevalence of smoking in ▪ Owing to the low number of individuals that Iceland declined following the 2008 economic crisis. change their smoking behaviours in a short This could be due to the procyclical relationship period, we were unable to assess the effects of a between macro-economic conditions and smoking change in employment on smoking habits. behaviour (ie, hard times lead to less smoking ▪ Findings are based on a low number of subjects because of lower affordability), or it may simply and must be taken with caution. reflect a continuation of trends already in place prior to the crisis. In individual-level analysis, we find that former smokers who experienced a decline in national and household debts, runaway income were less likely to relapse; and conversely, unemployment rates and decreased per 1 Department of Medicine, an increase in income raises the risk. However, capita purchasing power.12 Centre of Public Health caution is warranted since these findings are based Sciences, University of Previous research on the health conse- on small numbers. Iceland, Reykjavik, Iceland quences of the Icelandic economic collapse 2Department of Society, has suggested adverse impacts on cardiovas- Human Development, and cular and mental health among women.34 Health, Harvard School of In the broader literature on economic crises Public Health, Boston, Massachusetts, USA and population health, however, it has been 3College of Public Health and INTRODUCTION debated whether health moves in a procycli- Human Sciences, Oregon The Icelandic economy was severely affected cal or counter-cyclical direction to macroeco- State University, Corvallis, by the global economic collapse of 2008. nomic conditions. The work of Brenner5 Oregon, USA After a decade-long period of financial pros- beginning in the 1970s suggested that mor- Correspondence to perity the nation was plunged into a reces- tality is counter-cyclical, that is, when the Christopher Bruce McClure; sion of great severity, resulting in a severe economy is down, death rates—in particular, [email protected] currency crisis, as well as a drastic increase in suicides—rise. However, in more recent McClure CB, Valdimarsdóttir UA, Hauksdóttir A, et al. BMJ Open 2012;2:e001386. doi:10.1136/bmjopen-2012-001386 1 Economic crisis and smoking behaviour: prospective cohort study in Iceland years, a series of econometric studies have suggested that mortality is procyclical, that is, during economic – contractions death rates decline.6 9 There are plausible reasons for this unexpected finding—for instance, during the 1998 Korean financial crisis, economic activ- ity was so depressed that there was a detectable decline Figure 1 The cohort of the ‘Health and well-being’ study. in traffic-related mortality.10 Others have speculated— without direct evidence—that people are more likely to ‘ ’ n=3755. Figure 1 shows the cohort attrition over be over-worked and stressed during economic booms questionnaire waves. than during busts, having less time flexibility to engage in health promoting behaviours.11 12 Measures Few studies, however, have used individual-level data to Smoking status and behaviour test the association between recession and health, espe- cially smoking. Most of the evidence to date has been at In the questionnaire, we inquired about smoking status, the ecological level, though not all.13 For instance, Shaw that is, whether respondents were current smokers, had et al14 found a direct association between economic quit smoking or had never smoked. In order to examine the likelihood of relapsing or quitting following an eco- hardship and a propensity to smoke. Using US data, fi Ruhm12 previously reported that economic recession nomic collapse, respondents were strati ed according was associated with a decline in the prevalence of cigar- to their smoking status: non-smoker, relapsed and quit 15 smoking. ette smoking. A recent report from Gallus et al found fi that the recent economic contraction in Italy has Non-smoker: an individual was classi ed as a non- given rise to an increase in the percentage of current smoker if they responded that they did not currently — smoke on both the 2007 and 2009 assessments. smokers primarily for women. In the present study, we fi took advantage of the natural experiment afforded by Relapsed smoker: an individual was identi ed as the Icelandic crisis to examine the relationship between relapsed if they indicated that they (a) were a former changes in economic conditions and smoking behaviour. smoker on the 2007 questionnaire, but indicated they Utilising a prospective cohort of Icelandic adults had (b) smoked in any frequency in 2009. In our ana- assessed before (in 2007) and after the start of the col- lyses estimating the ORs of relapse, the base population lapse (in 2009), we sought to examine the risk of relapse was restricted to individuals who were former smokers at among precollapse former smokers, as well as quitting baseline. behaviour among current smokers in terms of economic Quit smoking: a respondent who had quit smoking changes. Furthermore, because of the important role of must have indicated that they were (a) currently smoking perceived stress on smoking status, we sought to in 2007, yet had (b) quit smoking by 2009. In our ana- examine the potential influence of stress on the studied lyses estimating the ORs of quitting, our base population associations.16 17 was restricted to individuals who were current smokers at baseline. METHODS Change in economic status Design and samples Additional socio-economic questions pertained to Cohort employment and income status. Household income was fi Our cohort is based on the Health and Wellbeing in Iceland classi ed into income ranges of (in terms of Icelandic ≤ health survey. Data were collected by a questionnaire currency; ISK) (1) low ( 3.4 million ISK), (2) middle – ≥ in two waves: (1) from October to December of 2007 (3.5 9.4 million ISK) and (3) high ( 9.5 million ISK); ≤ (10–12 months precollapse), then again (2) between corresponding approximately to (1) 28 000 US$, – ≥ November and December of 2009 (13–14 months post- (2) 28 000 77 000 US$ and (3) 77 000 US$. For analysis collapse). The cohort was based on a stratified random of income change, household income was further dichot- ‘ ’ sample of the Icelandic population (n=9807), which was omised into either high or low (which combined the selected from 12 strata: consisting of two geographic middle-income and low-income categories).
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