Trends in Absolute and Relative Educational Inequalities in Adult Smoking Since the Early 2000s: The Case of Germany.

Since the early 2000s, several tobacco control policies have been implemented in Germany. Current research is inconsistent about how strengthening tobacco control can affect social inequalities in smoking. This study examines whether educational inequalities in adult smoking have widened in Germany since 2003. Data were used from four cross-sectional national health surveys conducted between 2003 and 2012 (n = 54,197; age = 25-69 years). Participants who smoked daily or occasionally were classified as smokers. The regression-based Slope Index of Inequality and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in smoking, respectively. In each survey year, smoking was associated with lower education. Overall, crude and age-standardized smoking rates declined over time. Stratified by education, trends of declining smoking rates were observed only in the high and medium education groups, whereas no statistically significant trend was found in the low education group. Relative educational inequalities in smoking increased significantly in men (2003: RII=1.74, 95% confidence interval 1.46 to 2.07; 2012: RII = 2.25, 95% confidence interval 1.90 to 2.67; p-trend = .019). Absolute educational inequalities in smoking were not found to have changed significantly during the study period. In the course of declining smoking rates, educational inequalities in smoking persisted in both absolute and relative terms. In men, relative inequalities in smoking may even have widened within only 9 years. Tobacco control policies should not only be targeted at the entire population but also attempt to reduce social inequalities in smoking by focusing more on socially disadvantaged groups. Smoking is associated with lower education in most European countries and contributes to social inequalities in health. Since the beginning of the 2000s, Germany has implemented a variety of tobacco control policies to reduce smoking in the population. This study reveals that despite a general decline in adult smoking, educational inequalities in smoking have persisted and even widened in Germany since 2003. The findings emphasize that more targeted efforts are needed to tackle smoking-induced inequalities in health.

Hoebel J ，Kuntz B ，Kroll LE ，Finger JD ，Zeiher J ，Lange C ，Lampert T ... -  《-》

Changing educational inequalities in sporting inactivity among adults in Germany: a trend study from 2003 to 2012.

Hoebel J ，Finger JD ，Kuntz B ，Kroll LE ，Manz K ，Lange C ，Lampert T ... -  《BMC PUBLIC HEALTH》

[Trends in educational inequalities in smoking among adolescents in Germany : Evidence from four population-based studies].

Kuntz B ，Waldhauer J ，Moor I ，Rathmann K ，Richter M ，Orth B ，Piontek D ，Kraus L ，Zeiher J ，Lampert T ... -  《-》

24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil.

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

Bandi P ，Chang VW ，Sherman SE ，Silver D ... -  《-》

Educational and wealth inequalities in tobacco use among men and women in 54 low-income and middle-income countries.

Socioeconomic differentials of tobacco smoking in high-income countries are well described. However, studies to support health policies and place monitoring systems to tackle socioeconomic inequalities in smoking and smokeless tobacco use common in low-and-middle-income countries (LMICs) are seldom reported. We aimed to describe, sex-wise, educational and wealth-related inequalities in tobacco use in LMICs. We analysed Demographic and Health Survey data on tobacco use collected from large nationally representative samples of men and women in 54 LMICs. We estimated the weighted prevalence of any current tobacco use (including smokeless tobacco) in each country for 4 educational groups and 4 wealth groups. We calculated absolute and relative measures of inequality, that is, the slope index of inequality (SII) and relative index of inequality (RII), which take into account the distribution of prevalence across all education and wealth groups and account for population size. We also calculated the aggregate SII and RII for low-income (LIC), lower-middle-income (lMIC) and upper-middle-income (uMIC) countries as per World Bank classification. Male tobacco use was highest in Bangladesh (70.3%) and lowest in Sao Tome (7.4%), whereas female tobacco use was highest in Madagascar (21%) and lowest in Tajikistan (0.22%). Among men, educational inequalities varied widely between countries, but aggregate RII and SII showed an inverse trend by country wealth groups. RII was 3.61 (95% CI 2.83 to 4.61) in LICs, 1.99 (95% CI 1.66 to 2.38) in lMIC and 1.82 (95% CI 1.24 to 2.67) in uMIC. Wealth inequalities among men varied less between countries, but RII and SII showed an inverse pattern where RII was 2.43 (95% CI 2.05 to 2.88) in LICs, 1.84 (95% CI 1.54 to 2.21) in lMICs and 1.67 (95% CI 1.15 to 2.42) in uMICs. For educational inequalities among women, the RII varied much more than SII varied between the countries, and the aggregate RII was 14.49 (95% CI 8.87 to 23.68) in LICs, 3.05 (95% CI 1.44 to 6.47) in lMIC and 1.58 (95% CI 0.33 to 7.56) in uMIC. Wealth inequalities among women showed a pattern similar to that of men: the RII was 5.88 (95% CI 3.91 to 8.85) in LICs, 1.76 (95% CI 0.80 to 3.85) in lMIC and 0.39 (95% CI 0.09 to 1.64) in uMIC. In contrast to men, among women, the SII was pro-rich (higher smoking among the more advantaged) in 13 of the 52 countries (7 of 23 lMIC and 5 of 7 uMIC). Our results confirm that socioeconomic inequalities tobacco use exist in LMIC, varied widely between the countries and were much wider in the lowest income countries. These findings are important for better understanding and tackling of socioeconomic inequalities in health in LMIC.

Sreeramareddy CT ，Harper S ，Ernstsen L 《-》