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Smoking in Context

A Multilevel Analysis of 49,088 Communities in Canada

      Background

      The extent to which the prevalence of smoking in Canada varies across geographic areas independently of individual characteristics has not been quantified.

      Purpose

      To estimate the extent and potential sources of geographic variation in smoking among communities, health regions, and provinces/territories in Canada.

      Methods

      Data are from the Canadian Community Health Surveys conducted between 2001 and 2008 (n=461,709). Current cigarette smoking among adults (aged ≥18 years) was the primary outcome. Individual-level markers of SES were education, household income, and occupation. Contextual variables potentially related to smoking considered were provincial cigarette taxes, workplace smoking bans, and collective family norms discouraging smoking in communities. A multilevel logistic regression analysis was conducted to model variation in smoking at the geographic scale of communities, health regions, and provinces.

      Results

      Overall, the contribution of geography as a percentage of the total variation in smoking was 8.4%, with 2.4% attributable to provinces, 1.2% attributable to health regions, and 4.8% attributable to communities after adjusting for age, gender and survey period. In models that accounted for socioeconomic and demographic characteristics in addition to age and gender, the contribution of geography to the total variation in smoking was attenuated to 4.1%; with 2.0% at the province level, 0.4% at the health region level, and 1.7% at the community level. Within provinces/territories, the community variation in smoking ranged from 2.4% in Prince Edward Island to 9.1% in British Columbia. Nationally, 71% of community and 21% of provincial differences in smoking were explained by individual, socioeconomic, and demographic factors alone; the inclusion of contextual covariates explained an additional 27% of the variation among communities. Collective family norms discouraging smoking in a community was the strongest contextual predictor of individual smoking; provincial cigarette taxes and workplace bans were only modestly related to individual smoking behavior.

      Conclusions

      Geographic variation in smoking remained after accounting for individual, socioeconomic, and demographic characteristics, suggesting the importance of place, at the level of provinces and communities in Canada. Remaining community variation in smoking was largely attenuated after accounting for collective family norms discouraging smoking. Area-level influences such as the social and/or environmental conditions of provinces and communities may be important sources of variation in smoking and therefore need to be considered if rates of smoking are to be modified.
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      References

        • Peto R.
        • Lopez A.D.
        • Boreham J.
        • Thun M.
        Mortality from smoking in developed countries 1950–2000.
        2nd ed. Oxford University Press, 2006
        • Reid J.L.
        • Hammond D.
        Tobacco use in Canada: patterns and trends.
        Propel Centre for Population Health Impact, University of Waterloo, Ontario, Canada2011
        • Shields M.
        Smoking-prevalence, bans and exposure to second-hand smoke.
        Health Reports. 2007; 18: 67-85
        • Huisman M.
        • Kunst A.E.
        • Mackenbach J.P.
        Educational inequalities in smoking among men and women aged 16 years and older in 11 European countries.
        Tob Control. 2005; 14: 106-113
        • Ng E.
        • Wilkins R.
        • Gendron F.
        • Berthelot J.M.
        Dynamics of immigrants' health in Canada: Evidence from the National Population Health Survey.
        Statistics Canada, Ottawa2005
        • Reine I.
        • Novo M.
        • Hammarstrom A.
        Does the association between ill health and unemployment differ between young people and adults?.
        Public Health. 2004; 118: 337-345
        • Tucker J.S.
        • Ellickson P.L.
        • Klein D.J.
        Predictors of the transition to regular smoking during adolescence and young adulthood.
        J Adolesc Health. 2003; 32: 314-324
        • Subramanian S.V.
        • Jones K.
        • Duncan C.
        Multilevel methods for public health research.
        in: Kawachi I. Berkman L.F. Neighborhoods and health. Oxford University Press, Oxford2003
        • Duncan C.
        • Jones K.
        • Moon G.
        Context, composition and heterogeneity: using multilevel models in health research.
        Soc Sci Med. 1998; 46: 97-117
        • Macintyre S.
        • Ellaway A.
        Neighborhoods and health: an overview.
        in: Kawachi I. Berkman L.F. Neighborhoods and Health. Oxford University Press, New York, NY2003: 20-42
        • Bingenheimer J.B.
        • Raudenbush S.W.
        Statistical and substantive inferences in public health: issues in the application of multilevel models.
        Annu Rev Public Health. 2004; 25: 53-77
        • Subramanian S.V.
        • Glymour M.
        • Kawachi I.
        Identifying causal ecologic effects on health: potentials and challenges.
        in: Galea S. Macroscoial determinants of population health. Springer Media, New York2007: 301-331
        • Bobak M.
        • Jha P.
        • Nguyen S.
        Poverty and smoking.
        in: Jha P. Chaloupka F.J. Tobacco control in developing countries. Oxford University Press, Oxford2000: 41-61
        • Desmeules M.
        Appendix A: overview of National Population Health and Canadian Community Health Surveys.
        BMC Women's Health. 2004; 4: S35
        • Thomas S.
        • Wannell B.
        Combining cycles of the Canadian Community Health Survey.
        Health Rep. 2009; 20: 53-58
        • Statistics Canada
        CCHS Cycle 1.1 (2000-2001) public use microdata file documentation.
        Health Statistics Division, Statistics Canada, Ottawa2003
        • Beland Y.
        Canadian community health survey–methodological overview.
        Health Rep. 2002; 13: 9-14
        • Statistics Canada
        CCHS Cycle 2.1 (2003) public use microdata file documentation.
        Health Statistics Division, Statistics Canada, Ottawa2005
        • Copley T.T.
        • Lovato C.
        • O'Connor S.
        Indicators for monitoring tobacco control: a resource for decision-makers, evaluators and researchers.
        Canadian Tobacco Control Research Initiative, Toronto, Ontario2006
        • Statistics Canada
        National occupational classification for statistics (NOC-S).
        Statistics Canada, Ottawa, Canada2006
        • Statistics Canada
        2001 Census dictionary.
        Ministry of Industry, Ottawa, Canada2003
        • Statistics Canada
        Health regions: boundaries and correspondence with Census geography.
        Statistics Canada, Ottawa, Canada2007
        • Treff K.
        • Perry D.B.
        Finances of the nation 2007.
        Canadian Tax Foundation, Toronto2008
        • Goldstein H.
        Multilevel statistical models.
        Arnold, London2003
        • Subramanian S.V.
        The relevance of multilevel statistical models for identifying causal neighborhood effects.
        Soc Sci Med. 2004; 58: 1961-1967
        • Snijders T.A.B.
        • Bosker R.J.
        Multilevel analysis: an introduction to basic and advanced multilevel modeling.
        Sage Publications, London1999
        • Larsen K.
        • Merlo J.
        Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression.
        Am J Epidemiol. 2005; 161: 81-88
        • Health Canada
        Canadian Tobacco Use Monitoring Survey (CTUMS): Smoking Prevalence 1999-2010.
        Health Canada: Controlled Substances and Tobacco Directorate, Ottawa2010
        • Wilkins R.
        Postal code conversion file plus (PCCF+), version 5F: automated geographic coding based on the Statistics Canada Postal Code Conversion files, including postal codes through July 2009.
        Health Statistics Division, Statistics Canada, Ottawa, Canada2010
        • Blakely T.
        • Subramanian S.V.
        Multilevel Studies.
        in: Oakes J.M. Kaufman J.S. Methods in Social Epidemiology. Jossey-Bass, San Fransisco2006: 316-340
        • Diez Roux A.V.
        Next steps in understanding the multilevel determinants of health.
        J Epidemiol Community Health. 2008; 62: 957-959
        • Krieger N.
        • Chen J.T.
        • Waterman P.D.
        • Rehkopf D.H.
        • Subramanian S.V.
        Painting a truer picture of U.S. socioeconomic and racial/ethnic health inequalities: the Public Health Disparities Geocoding Project.
        Am J Public Health. 2005; 95: 312-323
        • Oliver L.N.
        • Hayes M.V.
        Does choice of spatial unit matter for estimating small-area disparities in health and place effects in the Vancouver Census Metropolitan Area?.
        Can J Public Health. 2007; 98: S27-S34
        • Gauvin L.
        • Robitaille E.
        • Riva M.
        • McLaren L.
        • Dassa C.
        • Potvin L.
        Conceptualizing and operationalizing neighbourhoods: the conundrum of identifying territorial units.
        Can J Public Health. 2007; 98: S18-S26
        • Walter Rasugu Omariba D.
        Neighbourhood characteristics, individual attributes and self-rated health among older Canadians.
        Health Place. 2010; 16: 986-995
        • Diez Roux A.V.
        Investigating neighborhood and area effects on health.
        Am J Public Health. 2001; 91: 1783-1789
        • Diez Roux A.V.
        Invited commentary: places, people, and health.
        Am J Epidemiol. 2002; 155: 516-519
        • Edwards S.A.
        • Bondy S.J.
        • Kowgier M.
        • McDonald P.W.
        • Cohen J.E.
        Are occasional smokers a heterogeneous group?.
        Nicotine Tob Res. 2010; 12: 1195-1202
        • Chow C.K.
        • Lock K.
        • Teo K.
        • Subramanian S.V.
        • McKee M.
        • Yusuf S.
        Environmental and societal influences acting on cardiovascular risk factors and disease at a population level: a review.
        Int J Epidemiol. 2009; 38: 1580-1594
        • Poland B.
        • Frohlich K.
        • Haines R.J.
        • Mykhalovskiy E.
        • Rock M.
        • Sparks R.
        The social context of smoking: the next frontier in tobacco control?.
        Tob Control. 2006; 15: 59-63
        • Parry O.
        • Thomson C.
        • Fowkes G.
        Cultural context, older age and smoking in Scotland: qualitative interviews with older smokers with arterial disease.
        Health Promot Int. 2002; 17: 309-316
        • Ross N.A.
        • Tremblay S.
        • Khan S.
        • Crouse D.
        • Tremblay M.
        • Berthelot J.M.
        Body mass index in urban Canada: neighborhood and metropolitan area effects.
        Am J Public Health. 2007; 97: 500-508