What accounts for the association of education and smoking cessation?

Abstract

Background.

Education has been identified as a potent sociodemographic predictor of smoking cessation and the Healthy People 2010 goals include the elimination of health disparities attributable to education.

Method.

The current study prospectively examined the association of education with smoking cessation as well variables that might account for that association among employed adults residing in the southeastern United States.

Results.

A strong educational gradient in cessation was evident. Only 6% of smokers with less than a high school (HS) degree quit smoking during the 4-year study period, whereas 17% of smokers with a HS degree but no college degree and 28% of smokers with at least a college degree quit smoking.

Conclusions.

Education appeared to uniquely contribute to the prediction of smoking abstinence over and above the effects of demographic, environmental, tobacco dependence, transtheoretical model, and job-related variables. Obtaining a better understanding of how or why education influences smoking cessation could contribute to reducing the educational gradient in abstinence and warrants further research attention.

Introduction

Despite public health efforts that have produced dramatic declines in the prevalence of cigarette smoking, it remains the leading cause of preventable disease and death in the United States [1]. However, smoking is not distributed equally across all facets of society, with education emerging as one of the strongest sociodemographic predictors of smoking prevalence and cessation (lower education is associated with higher prevalence and less cessation) [2], [3], [4], [5], [6]. Between 1974 and 1985, education surpassed gender as the strongest sociodemographic correlate of smoking and the rate of smoking cessation during that time increased twice as fast among smokers with higher levels of education as compared to those with lower levels of education [5], [7]. The most recent national data indicate that the quit ratio (percentage of ever smokers who have quit smoking) ranges from 34% among individuals with lower educational levels to 74% among individuals with graduate degrees [4]). Furthermore, the disparity in smoking cessation by educational level has been demonstrated cross-culturally, at least with respect to developed nations such as England, Denmark, Norway, and Spain [8], [9], [10], [11].

The elimination of health disparities, including those attributable to differences in education and other indicators of socioeconomic status, has been identified as a key goal of Healthy People 2010 [12]. Further, the recent National Conference on Tobacco and Health Disparities, convened to identify research gaps and develop an agenda to eliminate socioeconomic disparities related to tobacco use, recommended that future research on tobacco use should (1) investigate potential mediators of the relationship between low socioeconomic status and tobacco use, (2) more thoroughly examine the association among socioeconomic status, smoking initiation, and smoking cessation, and (3) determine how evidence-based treatments for tobacco dependence can best be utilized to treat special populations such as individuals with lower levels of education [13]. In summary, because education is a powerful sociodemographic predictor of smoking cessation [4], [5], [6] and in line with these public health goals and recommendations, the current study investigated educational disparities in smoking cessation as well as specific factors that might account for those disparities.

A recent social-contextual model of tobacco use [14] highlighted the importance of identifying the factors through which socioeconomic position influences cessation, as doing so could improve the impact of tobacco control efforts through more optimal selection of specific behavior change or policy mechanisms, as well as through more optimal targeting of high risk groups [15], [16]. Potential factors influencing the pathways between socioeconomic status and cessation include individual, interpersonal, organizational, neighborhood/community, and societal factors, and interventions should seek to modify mediating factors in an effort to influence patterns of tobacco use. For example, if low-educated smokers are less likely to quit smoking than are more highly educated smokers because they tend to be more nicotine dependent and employed in settings where there is less support for quitting, interventions targeting workplace social norms, smoking policies, and the provision of nicotine replacement therapies might reduce the educational gradient in cessation. Along these lines, a recent worksite health promotion intervention was successful in reducing occupational differences in smoking cessation by specifically addressing occupational risks important to blue collar workers [17].

Based on prior empirical findings and the social-contextual model, the current study focused on the role of job and tobacco-related variables in explaining the association of education and smoking cessation. A simple model was constructed in which educational level was hypothesized to influence tobacco-related variables and a constellation of job-related characteristics, which in turn, were hypothesized to influence smoking cessation. Previous research has linked low education to low job status [18]. Low job status is characterized by greater smoking prevalence [2], [19] as well as a social milieu where smoking is accepted and there is little encouragement for quitting [20], [21]. Moreover, low job status predicts less smoking cessation [2], [19], [22]. Therefore, job status and related variables (e.g., pay schedule, union membership, shift schedule), as well as the associated social environment (e.g., support for quitting, unacceptability of smoking at work), were hypothesized to partially account for the relation between education and smoking cessation.

Similarly, low education is associated with heavy smoking [23], [24], less knowledge of the health consequences of smoking [25], and lower readiness to quit smoking (i.e., stage of change; [26]). Each of these variables predicts lower rates of smoking cessation [27], [28], [29]. In the transtheoretical model, specific processes of change (experiential, behavioral) and beliefs about the pros and cons of smoking (decisional balance) are hypothesized to vary systematically with stage of change. Experiential processes tend to be used earlier in the stage progression and behavioral processes tend to be used later in that progression [30]. With respect to decisional balance, the pros of smoking outweigh the cons in the precontemplation stage with a crossover occurring in either the contemplation or preparation stage such that the cons of smoking come to outweigh the pros [27], [30]. Because individuals with lower educational levels tend to be less ready to quit, they should also use fewer behavioral processes of change and have higher pros and lower cons of smoking relative to individuals with higher levels of education. Therefore, tobacco-related variables associated with addiction models (e.g., cigarettes smoked per day, time to first cigarette) and the transtheoretical model of change (e.g., stage of change, processes of change, decisional balance) were hypothesized to partially account for the association of education and smoking cessation [27], [31].

Demographic and environmental variables were hypothesized to have little effect on the association between education and smoking cessation, in large part because education is clearly not a causal agent for many of these variables (e.g., age, gender, race/ethnicity), consistent relations with both education and cessation are lacking for some variables (e.g., marital status, living with children), and the direction of causality is indeterminate for other variables (e.g., alcohol use). Furthermore, recent data suggest that the socioeconomic gradient in smoking cessation generally holds across race and ethnicity (i.e., there does not appear to be a moderating influence of these demographic factors; [2]). Therefore, we hypothesized that demographic and environmental variables would have little effect on the relation between education and smoking cessation.

Data were collected in a large, community-based, longitudinal sample of employed smokers enrolled in the Working Well Trial (WWT), a cancer prevention study designed to test the efficacy of a worksite health promotion intervention [32], [33]. Education and other predictor variables were collected during a baseline survey with smoking cessation assessed at the final follow-up survey. Variables examined included demographics, environmental variables, job-related characteristics, and tobacco-related variables. To the best of our knowledge, this is one of the few studies to examine variables that might account for the relation between education and smoking cessation prospectively in a large community-based cohort.