Educational attainment and smoking among women: Risk factors and consequences for offspring
Introduction
The association between socioeconomic disadvantage, smoking, and morbidity and mortality in the population has been well established in the U.S. (U.S. Department of Health and Human Services, 2001, U.S. Department of Health and Human Services, 2007, Greaves et al., 2006, House, 2002, McCaffery et al., 2007, Mirowsky et al., 2000, Robert and House, 2000, Schaap et al., 2008, Schnittker and McLeod, 2005) as well as in other Western countries (Giskes et al., 2005, Graham et al., 2006). While socioeconomic indicators other than education contribute to disparities in rates of smoking (Schaap et al., 2008), education, which is highly related to overall status (Laaksonen et al., 2005), is the most frequently used indicator of socioeconomic status (SES) in studies of smoking (Schaap et al., 2008). The disparity in smoking rates related to educational level persists even in societies with a strong welfare system (Eikemo et al., 2007, Olafsdottir, 2007).
The negative association between educational level and smoking among women is also observed in pregnancy (Kahn et al., 2002, Matthews, 2001). Smoking during pregnancy has special public health relevance because of the impact of prenatal smoking on offspring. Children whose mothers have smoked during pregnancy are more likely to smoke in adolescence (Al Mamun et al., 2006, Cornelius et al., 2000, Kandel et al., 1994, unpublished data; O’Callaghan et al., 2006) and to become dependent on nicotine (Buka et al., 2003). Furthermore, epidemiological, clinical and animal studies have also established that offspring of mothers who smoke during pregnancy are more likely to manifest behavior problems, both externalizing and internalizing (D’Onofrio et al., 2008, Griesler et al., 1998, Kahn et al., 2005, Milberger et al., 1996, Orlebeke et al., 1997, Richardson and Tizabi, 1994, Shea and Steiner, 2008, Vaglenova et al., 2004, Wakschlag et al., 2002, Wakschlag et al., 2006, Weissman et al., 1999, Winzer-Serhan, 2008). Behavioral disturbances, e.g., hyperactivity and conduct disorder, are risk factors for delinquency and substance use (Moffitt, 1993), in particular smoking (Brown et al., 1996, Kollins et al., 2005, Lynskey and Fergusson, 1995), and nicotine dependence (Breslau et al., 1993, Storr et al., 2004). Effects on child smoking may be direct due to an induced biological vulnerability to the addictive properties of nicotine and indirect through nicotine induced behavioral problems in childhood. It is not clear to what extent the impact of prenatal smoking varies according to SES.
Why is there such a strong negative relationship between educational attainment and smoking? How is educational level associated with differential exposure to risk factors that contribute to smoking? Education is related to most aspects of a person's lifestyle, social performance and psychosocial adjustment, including participation in the labor force, family roles, parenting, and psychological well being. The higher the education, the higher the labor force participation and marriage rates, and the lower the levels of psychological distress and depression (Lorant et al., 2003, Thornton et al., 1995, U.S. Census Bureau, 2007). Thus, at any particular historical point in time, the association between SES and a health-related behavior, such as smoking, could be accounted for by differential attitudes about heath related behaviors, differential psychosocial characteristics, and differential participation in the social roles of adulthood.
In this article, we address four issues:
- (1)
What is the association between education and patterns of smoking among women?
- (2)
Do these patterns persist with control for covariates?
- (3)
What is the association between education and patterns of smoking in pregnancy?
- (4)
Does education account for the impact of prenatal smoking on offspring smoking and psychosocial adjustment?
We provide a broad overview of these issues and new empirical findings rather than an in-depth exploration of each question. We explore these issues in multiple data sets that each provides unique information to illuminate a particular question. We use data from three surveys to explore the first two issues: the National Survey on Drug Use and Health (NSDUH 2006) (Substance Abuse and Mental Health Services Administration, 2007a), the National Longitudinal Survey of Adolescent Health (ADD HEALTH III) (Harris et al., 2003, Kandel et al., 2007a), and the National Health and Nutrition Examination Survey (2005–2006) NHANES (National Center for Health Statistics, cdc.gov/nchs/nhanes.htm accessed on 3/4/2008). We use data from The National Longitudinal Survey of Youth (NLSY) (1979–2004) (Center for Human Resource Research, 2006) to explore the last two issues.
We explicitly do not deal with questions related to race/ethnicity, although these are relevant to socioeconomic disadvantage, because race/ethnicity is the specific focus of the article by Wallace (2009). However, we control for race/ethnicity in our statistical models.
Section snippets
Data sources
Greater detail about each of the four national surveys and the measurement of variables of interest is provided in the references cited for each study, although we briefly describe the design and selected variables for each study.
Education and smoking behavior
The association between education and patterns of smoking differs for lifetime and current (last 30 days) smoking. An inverse relationship appears with respect to current but not lifetime smoking. As documented by NSDUH 2006, women with less than a high school education are less likely to have ever smoked (54.7%) than high school graduates (65.9%), those with some college (70.3%), or college graduates (66.6%). The opposite pattern characterizes current smoking, for which college graduates have
Conclusion
Disparities in women's smoking by educational level are pervasive. This study provides further confirmation for the observation that lower education significantly increases the risk of smoking and smoking heavily (Yang et al., 2008, Marmot and Wilkinson, 1999).
The negative impact of educational disadvantage for smoking by women persists with controls for participation in adult social roles, attitudes toward drug use, religiosity, and other predictors of smoking behavior. Each of these factors,
Conflict of interest
The authors declare that they have no conflicts of interest.
Acknowledgements
One of the four data sets used in the research is from ADD HEALTH, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by a grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. No direct support was received from grant P01-HD31921 for
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