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Socioeconomic Inequalities in Youth Smoking in Brazil

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Socioeconomic Inequalities in Youth Smoking in Brazil Open Access Research BMJ Open: first published as 10.1136/bmjopen-2013-003538 on 2 December 2013. Downloaded from Socioeconomic inequalities in youth smoking in Brazil Sandhi Maria Barreto,1 Roberta Carvalho de Figueiredo,1 Luana Giatti1,2 To cite: Barreto SM, ABSTRACT Strengths and limitations of this study de Figueiredo RC, Giatti L. Objective: The contribution of smoking to Socioeconomic inequalities in socioeconomic inequalities in health is increasing ▪ youth smoking in Brazil. BMJ The main strength of this study is its analysis of worldwide, including in Brazil. Youth smoking may play an Open 2013;3:e003538. the social determinants, at the household and doi:10.1136/bmjopen-2013- important role in the increasing social inequalities related individual levels, of teenage smoking using a 003538 to smoking. This study investigates social determinants of nationwide household sample in a large smoking among 15-year-old to 19-year-old individuals. middle-income country. Design: Cross-sectional study. ▪ ▸ Prepublication history for The main limitation is the lack of information this paper is available online. Setting: The study uses data of 3536 participants aged about the relationship between adolescents and To view these files please 15–19 years of age of the Global Adult Tobacco Survey other smokers in the household. visit the journal online (GATS) and the National Household Sample Survey ▪ Results reinforce that household smoking restric- (http://dx.doi.org/10.1136/ (Pesquisa Nacional por Amostragem de Domicilio, PNAD) tions protect against adolescent smoking. bmjopen-2013-003538). obtained from household interviews. Smoking was defined as currently smoking tobacco products, regardless Received 3 July 2013 of frequency. Household socioeconomic indicators and older decreased 48%, from 34.8% in 1989 Revised 15 October 2013 1 included per capita income, the educational level and sex to 18.2% in 2008, preventing almost 420 000 Accepted 16 October 2013 2 of the head of the household, the presence of smoking (260 000–715000) deaths. Such achievements restrictions and the number of smokers (excluding have been attributed largely to Brazil’sstrong adolescents). Adolescent social factors included years of upstream anti-tobacco policies, combined with delaying school and social status (full-time student, an increased access to tobacco cessation working, and neither working nor studying). The treatments.23 hierarchical logistic regression analysis considered the However, the contribution of smoking to effect of the complex sampling design. socioeconomic inequalities in health is increas- http://bmjopen.bmj.com/ Results: From 3536 participants, 6.2% were smokers ing in Brazil. According to data from the (95% CI 5.4 to 7.1). More men than women had the habit World Health Survey, 2002–2004, smoking of smoking (7.2%; 5.9 to 8.6 vs 3.6%; 2.7 to 4.6). The likelihood of smoking was significantly greater for men rates were higher among poor men and and older teens. There was an upward trend in the OR of women (74% and 59%, respectively), even smoking according to the number of smokers in the after controlling for age, marital status, educa- 4 house. Adolescents living in households with no smoking tion, employment and urban/rural residence. restrictions had a greater likelihood of being smokers. OR The results of the Global Adult Tobacco of smoking rose as the number of years of delaying Survey (GATS) Brazil showed that there were on September 24, 2021 by guest. Protected copyright. school increased, being about three times greater among almost twice as many tobacco users with no or adolescents who were working and five times greater less than a year of schooling, compared with among those who were neither studying nor working. tobacco users with 11 or more years of Conclusions: Results demonstrate that socioeconomic education.5 inequality in smoking is established at younger ages and Early initiation of tobacco use could be a key that school delay as well as school abandonment may component in the increasing social inequal- contribute to increased smoking-related inequalities. Smoking restrictions at home were protective against ities of smoking and its related morbidity and 1 6 Faculty of Medicine, adolescents becoming smokers. Living with other mortality. Analyses of three birth cohorts in Postgraduate Program in smokers was a strong predictor of adolescents becoming Italy showed that the increase in smoking Public Health, Universidade smokers. inequalities among men and women was Federal de Minas Gerais, Belo Horizonte, Brazil mainly due to growing inequalities in smoking 2Department of Clinical and initiation rates. Studies have shown that most Social Nutrition, Universidade regular adult smokers become addicted in – Federal de Ouro Preto, Ouro their teens.7 9 In addition, early smoking has Preto, Brazil INTRODUCTION been associated with higher levels of tobacco fi Correspondence to Cigarette smoking has fallen sharply in Brazil; dependence, increased dif culty in smoking Professor Sandhi M Barreto; in approximately two decades, the smoking cessation and more negative health outcomes – [email protected] prevalence among individuals aged 18 years in adulthood.10 13 Barreto SM, de Figueiredo RC, Giatti L. BMJ Open 2013;3:e003538. doi:10.1136/bmjopen-2013-003538 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2013-003538 on 2 December 2013. Downloaded from In 2004, approximately 70% of adult smokers residing socioeconomic factors included location (urban, rural), in large Brazilian cities had begun to smoke before the household per capita income grouped in quintiles, age of 20 years.14 However, youth smoking seems to be highest education level attained by the head of the more frequent among socially disadvantaged household in number of years completed (0–8, 9–11, groups.15 16 In Brazil, among daily or former daily 12–14, 15 and more) and female head of household smokers, the proportion of individuals who started (no, yes). smoking before 15 years of age was twofold greater The second set of covariables consisted of household among those with no or less than 1 year of schooling smoking characteristics, which included the number of than among those with 8 years of schooling or more.5 smokers in the household, excluding the participating A few studies have specifically addressed the social adolescent (0, 1, 2, 3 or more) and smoking restrictions – determinants of teenage smoking in Brazil,17 19 and at home (not allowed, generally not allowed and none has been undertaken in a nationwide household allowed). The category ‘allowed’ also included an sample. This study investigated the social determinants absence of smoking restrictions. of current smoking among participants of 15–19 years of The last set of covariables included the adolescents’ age in the GATS Brazil. In particular, we investigated characteristics: sex; age (15, 16, 17, 18, and 19 years); whether school delay and abandonment, as well as early self-declared race/skin colour (white, black, brown, entry to work, which are regarded as early markers of Asian descent and indigenous); social status (full-time future socioeconomic disadvantage, were independently student, only working, working and studying and neither associated with smoking among teenagers. studying nor working); school delay, defined as the dif- ference in years of schooling between the individual’s current school grade and the school grade in which he/ METHODS she was expected to be given his/her age (none, 1, 2, Participants 3 years or more). A negative difference in school delay This study used data from GATS, which was carried out was treated as no difference. The Asian descent and in a random subsample of the National Household indigenous were combined as ‘other’ because the Sample Survey (Pesquisa Nacional por Amostragem de number of individuals was very small. Domicilio, PNAD). PNAD was conducted in 2008 by the Brazilian Institute of Geography and Statistics (Instituto Statistical analysis fi Brasileiro de Geogra a e Estatstica, IBGE) and the First, we described the prevalence of smoking, the pro- Ministry of Health. PNAD and GATS Brazil used a four- portion (with 95% CIs) of daily smokers, age at initiation stage complex probabilistic household sample (munici- and the mean and median numbers of cigarettes pality, census tract, household and individual) and was smoked per day by sex. Next, we performed a descriptive http://bmjopen.bmj.com/ representative of the national and regional levels. analysis of the distribution of adolescents according to Further details on the sampling design can be found at individual and household socioeconomic indicators fi http://www.who.int/tobacco/surveillance/en_t _gats_ (table 1). 2010_brazil.pdf. Associations between each explanatory variable and The PNAD questionnaires provided socioeconomic current smoking were measured by Pearson’s χ2 test with information about households and selected individual a p value <0.05. Variables with p<0.20 were included in characteristics and health-related factors, and the GATS the multivariable analysis. The magnitude of the associa- questionnaire provided a detailed information on tions was measured using ORs, and 95% CIs were on September 24, 2021 by guest. Protected copyright. tobacco use and exposure. GATS Brazil aimed to obtained by multiple logistic regression. The ‘svy’ pro- include 40 000 individuals aged 15 years and older with cedure, available in Stata V.11.0, was used to account for a response rate of 95.2%. Of 39
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