1. Socioeconomic Status and Smoking in Canada, 1999-2006 : Has there been any progress on disparities in tobacco use? Jessica Reid, David Hammond, Pete Driezen Dept. of Health Studies, University of Waterloo CPHA Annual Conference June 1-4, 2008, Halifax

2. Background: Tobacco Use & SES Tobacco use is the leading cause of preventable death in Canada: 47,000 deaths/yr Tobacco use is the leading cause of preventable death in Canada: 47,000 deaths/yr Overall smoking prevalence has decreased over time; changing demographics of smokers Overall smoking prevalence has decreased over time; changing demographics of smokers Socioeconomic gradient in smoking, with higher rates in lower SES groups Socioeconomic gradient in smoking, with higher rates in lower SES groups Tobacco use is a major contributor to overall health inequalities Tobacco use is a major contributor to overall health inequalities Makomaski Illing, 2004, (de Walque, 2004; Giskes et al., 2005, Jarvis & Wardle, 2006; Jha et al., 2006, Makomaski Illing, 2004, Physicians for a Smoke-free Canada, 2005)

3. Rationale Population-level interventions (policies and programs) may have differential effects by SES ( or ) Population-level interventions (policies and programs) may have differential effects by SES ( or ) Research needed to determine effects of recent tobacco control efforts on tobacco- related disparities Research needed to determine effects of recent tobacco control efforts on tobacco- related disparities Important to monitor SES trends in smoking and quitting Important to monitor SES trends in smoking and quitting

4. Objectives 1.To evaluate whether smoking prevalence and related constructs (quit ratio, consumption, smoking frequency, quitting intentions and attempts) vary by socioeconomic status. 2.To examine whether any identified differences have changed over time, from 1999-2006.

5. Canadian Tobacco Use Monitoring Survey (CTUMS) Conducted by Statistics Canada Conducted by Statistics Canada Repeated cross-sectional surveys Repeated cross-sectional surveys Nationally representative samples Nationally representative samples Conducted Feb.-Dec. every year, 1999- Conducted Feb.-Dec. every year, 1999- Telephone interviews Telephone interviews

6. Study Sample Analysis limited to ≥ 25 years of age Analysis limited to ≥ 25 years of age Total n=86 971 (>10 000 per year) Total n=86 971 (>10 000 per year) ~10% from each province ~10% from each province 56% female 56% female Mean age: 49.5 years Mean age: 49.5 years Education level: Education level: Less than secondary: 23.79% Less than secondary: 23.79% Completed secondary: 38.29% Completed secondary: 38.29% Completed community college: 16.59% Completed community college: 16.59% Completed university: 21.33% Completed university: 21.33%

7. Measures: Dependent Variables Total population: Total population: Smoking prevalence (y/n) Smoking prevalence (y/n) Quit ratio (former/ever smokers; continuous) Quit ratio (former/ever smokers; continuous) Smokers: Smokers: Smoking frequency (daily vs. occasional) Smoking frequency (daily vs. occasional) Consumption – cigarettes per day (continuous ) Consumption – cigarettes per day (continuous ) Seriously considering quitting in next 6 months (y/n) Seriously considering quitting in next 6 months (y/n) Made ≥ 24-hour quit attempt in past year (y/n) Made ≥ 24-hour quit attempt in past year (y/n)

8. Measures: Independent Variables SES: Education (4 categories) SES: Education (4 categories) Demographics: Demographics: Age (continuous, range: 25-85) Age (continuous, range: 25-85) Sex (categorical: 0 - male, 1 - female) Sex (categorical: 0 - male, 1 - female) Region (categorical: Atlantic, Quebec, Ontario, Western, BC) Region (categorical: Atlantic, Quebec, Ontario, Western, BC) Consumption (cigarettes per day (CPD)) *quitting analyses only Consumption (cigarettes per day (CPD)) *quitting analyses only Time (survey year) Time (survey year)

9. Analysis Regression modeling (logistic and multiple linear) using SAS software Regression modeling (logistic and multiple linear) using SAS software Data from individual respondents examined in each year for association of education and outcomes Data from individual respondents examined in each year for association of education and outcomes Summary data set created with proportion or mean for each outcome by age/sex/region/ education level, used to test for time trend and interaction of time*education Summary data set created with proportion or mean for each outcome by age/sex/region/ education level, used to test for time trend and interaction of time*education

10. Results: Smoking prevalence Overall, decrease from 24% (1999) to 18% (2006) Overall, decrease from 24% (1999) to 18% (2006) Significant association with time (p<0.0001) Significant association with time (p<0.0001)

11. Results: Smoking prevalence *Includes all current smokers (daily and occasional)

12. Results: Smoking prevalence Less educated more likely to smoke in each year Less educated more likely to smoke in each year No interaction of time*education (p=0.22) No interaction of time*education (p=0.22)

13. Results: Daily/Occasional Smoking Overall, decrease from 85% daily (1999) to 79% (2006) Overall, decrease from 85% daily (1999) to 79% (2006) Significant association with time (p<0.0001) Significant association with time (p<0.0001)

14. Results: Daily/Occasional Smoking Among smokers, less educated more likely to smoke daily in each year; few exceptions Among smokers, less educated more likely to smoke daily in each year; few exceptions No time*education interaction (p=0.10) No time*education interaction (p=0.10)

15. Results: Consumption (CPD) Overall, decrease from 16.4 (1999) to 13.6 (2006) CPD Overall, decrease from 16.4 (1999) to 13.6 (2006) CPD Significant association with time (p<0.0001) Significant association with time (p<0.0001)

16. Results: Consumption (CPD) Significant effect of education (p<0.0001) Significant effect of education (p<0.0001) No time*education interaction (p=0.73) No time*education interaction (p=0.73)

17. Results: Quit Intentions No significant differences by education No significant differences by education Exception: 2001, uni. vs. <sec. OR=1.98 (1.19-3.31) Exception: 2001, uni. vs. <sec. OR=1.98 (1.19-3.31) Significant association with time (p<0.0001) Significant association with time (p<0.0001) No time*education interaction (p=0.37) No time*education interaction (p=0.37)

18. Results: Quit Attempts No significant differences by education No significant differences by education Exception: 2005, uni. vs. <sec. OR=0.52 (0.29-0.92) Exception: 2005, uni. vs. <sec. OR=0.52 (0.29-0.92) No significant association with time (p=0.88) No significant association with time (p=0.88) Significant time*education interaction (p=0.02) Significant time*education interaction (p=0.02)

19. Results: Quit ratios University grads significantly higher than others University grads significantly higher than others (except college in 2006, <secondary in 2000, 2003, 2004) Significant association with time (p<0.0001) Significant association with time (p<0.0001) No time*education interaction (p=0.33) No time*education interaction (p=0.33)

20. Summary and Conclusions Considerable SES disparities in smoking exist in Canada, for prevalence and consumption Considerable SES disparities in smoking exist in Canada, for prevalence and consumption Good news: such disparities have not widened considerably, but... Good news: such disparities have not widened considerably, but... Bad news: they have not decreased either Bad news: they have not decreased either Good news: lower SES groups are not less likely to intend to quit or attempt to quit, but... Good news: lower SES groups are not less likely to intend to quit or attempt to quit, but... whether/how this may translate into cessation is unknown whether/how this may translate into cessation is unknown Recent policies do not seem to be worsening disparities, but are unlikely to reduce them Recent policies do not seem to be worsening disparities, but are unlikely to reduce them

21. Acknowledgements Data: This study analysed public-use data collected by Statistics Canada. The results and views expressed in this paper are those of the authors and are not those of Statistics Canada. Data: This study analysed public-use data collected by Statistics Canada. The results and views expressed in this paper are those of the authors and are not those of Statistics Canada. Student funding: The first author is supported by a CIHR Strategic Training Program in Tobacco Research (STPTR) Fellowship and an Ontario Graduate Scholarship. Student funding: The first author is supported by a CIHR Strategic Training Program in Tobacco Research (STPTR) Fellowship and an Ontario Graduate Scholarship. Conference attendance: CPHA Population and Public Health Student Award (Master’s Level) Conference attendance: CPHA Population and Public Health Student Award (Master’s Level)

22. Thank you. Questions?