0277-9536191 $3.00 + 0.00 Copyright Q 1991 Pergamon Press plc
Sot. Sci. Med. Vol. 33, No. II, pp. 1309-1312, 1991 Printed in Great Britain. All rights reserved
CIGARETTE
SMOKING
AND EMPLOYMENT
STATUS
AMANDA J. LEE,* IAIN K. CROMBIE,WILLIAM C. S. SMITH and HUGH D. TUNSTALL-PEDOE Cardiovascular Epidemiology Unit, Ninewells Hospital and Medical School, Dundee DDl 9SY, U.K.
Abstract-The smoking habits and health kncwledge of the unemployed and the full-time workers were investigated in a cross-sectional study of over 10,000 men and women throughout Scotland. For both sexes (age range 40-59 years), the proportion of current smokers and ever smokers was found to be considerably higher among the unemployed. Only a small part of the difference could be explained by standardisation for social class. The unemployed smokers had began to smoke at an earlier age, with significantly more smoking whilst still at school. Amongst current smokers, the unemployed males reported smoking fewer cigarettes a day, whereas unemployed women smoked more than their full-time counterparts. The reported levels were confirmed by the biochemical measures of smoking; serum thiocyanate and expired air carbon monoxide levels. In contrast to their differences in smoking habit, the two groups were very similar in their knowledge of the hazards of smoking. Smoking habits among the unemployed reflect a complex interaction of financial and both current and previous social factors. Such relationships present a particular challenge to health promotion campaigns. Key words-unemployment,
smoking habits, health knowledge
INTRODUCTION
haviour [20] and health knowledge and behaviour. In addition, each subject underwent a physical examinIn recent years concern about the health of the ation and had a blood sample taken. unemployed has increased [l-4]. Several studies have Data on current employment status was catefound both a higher mortality [5-71 and a_ higher gorised into one of seven groups: full-time job, partmorbidity [8-lo] amongst this group when compared time job, unemployed seeking work, unemployed to those in full-time employment. Recent studies indicate that the unemployed drink more alcohol [ 111 because sick or disabled, housewife, wholly retired from employment and full-time student. Social class and smoke more cigarettes [12, 131 than those in was determined by present occupation using the employment. Further, this latter difference persists Office of Population Censuses and Surveys codes [21]. even after standardisation for age, social class and If the subject was currently unemployed, then social town of residence [14]. The Scottish Heart Health Study (SHHS) is a class was derived from their last known occupation. Married women were classified by their husbands cross-sectional survey of cardiovascular risk factors occupation. in representative samples of men and women Subjects were split into three groups on the basis throughout Scotland. Results concerning the major of their current smoking status: current cigarette risk factors and life-style variation across Scotland smokers, ex-cigarette smokers and ever smoked cigahave been published [15,16]. This paper contrasts the rettes. A current smoker was someone who had said smoking behaviour of the unemployed with that of that they now smoked cigarettes regularly or octhe full-time employed and it uses objective biochemicasionally. An ex-smoker was someone who used to cal tests to confirm self-reported levels of smoking. be a regular or occasional (usually less than one a Furthermore, differences between knowledge of the day) smoker. The ever-smoked group was the sum of health hazards of smoking and the actual smoking the previous two. During the physical examination, levels are compared. In doing this, the appropriateexpired carbon monoxide was determined using a ness of the health belief model [17] in the two groups Bedfont EC50 analyser. Serum thiocyanate was asis compared. sayed by a calorimetric method on a COBAS Bio centrifugal fast analyser. METHODS
The SHHS was designed to investigate the levels of Coronary Heart Disease (CHD) mortality and its geographic variation in Scotland [18]. A random sample of 10,359 men and women aged 4&59 years from 22 local government districts were used [19] representing 74% of those known to be resident at the time of the survey. A self completed questionnaire included questions on basic demographic details, occupational and employment status, smoking be*To whom correspondence and reprint requests should be addressed.
RESULTS
Overall, 81.9% of the men and 32.8% of the women were currently in full-time work although a further 31.1% of women were in part-time employment (Table 1). There were considerably more unemployed males than females possibly because some women regarded themselves as housewives rather than unemployed. Although data on seven employment categories were available, this paper concentrated on the full-time workers and the unemployed because of the small numbers in other categories.
1309
1310 Table
AMANDA J. LE et al.
I. Current employment status of the study participants
Full-time Part-time Unemployed (active) Unemployed (sick or disabled) Retired Student Housewife Overall N
Male
Female
81.9(4177) 0.8 (43) 9.4 (480)
32.8(1705) 31.1 (1618) 2.6(136)
5.8 (298)
3.2(165)
1.9(96) 0.1 (6) 5100
2.1 (111) 0.2 (9) 28.0(1453) 5197
Table 3. Smoking behaviour by social class and employment status standard&d for social class among men Male
% Current smokers
% % % %
both sexes, smoking is considerably more common among the unemployed (62.7% men and 50.7% of women) compared to those in full-time employment (35.4% men and 37.5% women). Among men, the proportions of ever-smoked are much closer. This difference is due to the lower proportion of ex-smokers among the unemployed (Table 2). However, this is not true for women where a considerably higher percentage of unemployed females have smoked at some time during their lives. The relatively small numbers of unemployed women indicate that this is a difficult group to define. A large number of the women classified themselves as either part-time workers or housewives. Further analysis showed that the smoking behaviour of these two groups resembled that of the full-time employed women: 37.3% of the part time women and 35.5% of the housewives were current smokers with the proportions of ever smokers being 57.2% and 56.3% respectively. It is known that both unemployment and smoking show strong social class gradients [22-251. Table 3 shows the expected trend in smoking by social class and also shows that for each social class group, the percentage of unemployed male current smokers was higher than their full-time counterparts. Furthermore, the prevalence of smoking among the unemployed in social classes I and II was higher than that of employed men from social classes IV and V. Due to the small number of unemployed women the female groups could not reliably be presented in this way. Direct standardisation for social class appears to have little effect on the proportions of male current and ex-smokers. Thus, only a small part of the higher smoking proportions among the male unemployed can be explained in terms of a differing social class structure. Further analysis showed no evidence of an interaction between smoking behaviour, district sampled and unemployment (data not presented). People who are destined to become unemployed later on in life may be socially different from the full-time workers. The percentage who began to smoke before reaching fifteen years old was signifiIn
Social class
Full-time
I, II IIIN IIIM IV, v
24.6 (382) 31.6(135) 42.7 (655) 45.5 (292)
52.0 (26) 53.3 (16) 62.5(150) 67.1 (104)
38.4 (1464) 36.0 (1490) 72.2 (2954) 29.8 (1197)
60.5 (296)*** 21.5(97)*** 80.6 (393j*** 20.7 (82)’
Current smokers’ Ex-smokers’ Ever smoked’ Never smoked’
*P < 0.05, l*P < 0.01, l**P < 0.001. aStandardised for social class.
cantly higher (P < 0.01) among the male unemployed (36.2%, n = 144) than among the employed males (24%, n = 714). Similarly, IO% (n = 10) of the unemployed females started smoking &fore this age compared to 6.8% (n = 67) of the full-time employed females. Furthermore, the unemployed males had slightly less years of education (average 10.1) than the employed males (average 11.2). The corresponding female figures were 10.6 and 11.5 years. Even though a greater percentage of the unemployed currently smoke, the question arises of whether they actually smoke more cigarettes? On average, the unemployed males smoked fewer cigarettes a day than the employed males. This finding was confirmed by lower serum thiocyanate and expired air carbon monoxide levels among the male unemployed (Table 4). In contrast, the unemployed females reported higher daily cigarette consumption which was substantiated by elevated thiocyanate and carbon monoxide levels. In contrast to the smoking levels, high proportions of both the unemployed and employed thought that by giving up smoking they could reduce their chances of having a heart attack (Table 5). Despite holding these views, the actual percentage of current smokers who had tried to smoke less in the preceding year was almost half the number who thought smoking harmful. The values were comparable for the two employment groups. DISCUSSION
This study has confirmed earlier reports on smoking and unemployment, but has also shed new light on the complexity of this association. As has been previously reported [ 13,261 a higher smoking prevalence among the unemployed of both sexes was found. Consistent with earlier reports [27-291 this study has found that smoking is more common in social
Table 2. Smoking behaviour by current employment status Female
Male % % % %
Current smokers Ex-smokers Ever smoked Never smoked
Unemployed
Full-time
Unemployed
Full-time
Unemployed
35.4 (1447) 35.9 (1496) 71.3 (2973) 28.7 (1200)
62.7(301)*‘* 20.2 (97)‘** 82.9 (398)“. 17.1 (82)**
37.5 (639) 20.3 (346) 57.8 (985) 42.2 (719)
50.7 (69)’ 22.8 (31) 73.5 (loo)**’ 26.5 (36)’
‘P < 0.05, ‘*P < 0.01, l**f r: 0.001 Note: No smoking data was available for a small number of subjects.
1311
Cigarette smoking and employment status Table 4. Cigarette consumption
and biochemical measures of smoking of current smokers by emulovmcnt status Female
Male
Mean no. cigs/day Mean serum thiocyanate (8moVl) Mean expired air carbon monoxide (ppm)
Full-lime
Unemployed
Full-time
Unemployed
21.1 (10.3) 120.3 (39.2)
19.9 (9.5) 119.1 (39.7)
16.8 (7.7) 129.6(47.1)
18.1 (6.2) 140.5 (38.6)
Zl.S(l3.6)
22.9 (13.1)
24.5 (14.1)
22.4(12.4)**
Mean (SD). l*P < 0.01.
Table 5. Health knowledge and behaviour of current smokers by employment status Male
Q: Do you think that stopping smoking may reduce your chance of having a heart attack? % Answering YES Q: Over the last year, have you tried to smoke fewer cigarettes? % Answcrina YES
Female
Full-time
Unemployed
Full-time
Unemployed
92.0(1318)
86.2 (250)
92.4 (574)
92.8 (64)
49.1(712)
48.0 f 142)
61.5 (384)
62.3 (43)
classes IV and V than classes I and II. As a higher proportion of the unemployed come from the lower social classes [30], the male smoking data were standardised for social class. This standardisation did not alter the higher levels of smoking among the unemployed, and has been reported elsewhere [12, 141. An additional finding was that more of the unemployed began smoking before the age of fifteen. This suggests that there may be other more subtle social differences between the two groups than simply social class since social class is based on occupation only. The consequences of unemployment on smoking behaviour are difficult to predict. On the one hand, it might be thought that the financial consequences of job loss would lead to stopping smoking or reducing consumption. On the other hand, the enhancement of stress that unemployment entails could cause a boost in consumption and/or expansion in the numbers who smoke. Nevertheless, the proportions who gave up smoking within the previous 5 years were similar among the employed and the unemployed (data not presented). We also found that the unemployed men actually smoked fewer cigarettes than the full-time employed males. These differences in the average number of cigarettes smoked were consistent across the social groups for both sexes. Changes in smoking habit can be accompanied by a compensatory increased inhalation effect [31]; such an effect would be seen by higher levels of the biochemical indicators. However, we found no evidence of this since our results were confirmed by lower thiocyanate and carbon monoxide levels. Validation of self-reported smoking behaviour with smoking biochemistry is an important point and one which is rarely reported. In contrast to the men, women out of work had higher consumption levels (again validated by the smoking biochemical indicators) when compared to the full-time employed females. Using the health belief model approach [17], there is an obvious difference between what people believe
and what they do with regard to smoking. Almost all of the smokers knew that giving up smoking would decrease their risk of a heart attack. However, the actual percentages who had tried to reduce their consumption in the previous twelve months was low. These limited data further demonstrate that the unemployed smokers were similar to the employed smokers in their knowledge of the hazards of smoking and in their recent attempts to stop. Due to the nature of unemployment, there may be a time lag between job loss and changes in health behaviour [32]. However, one limitation to the present study was that no information was available on the length of time a person had been out of work. There is a need for prospective studies in this field. In conclusion, the smoking habits of the unemployed reflect a complex interaction of both financial and social factors. As we found no difference in the health knowledge of the effects of smoking between the two employment groups, this suggests that education campaigns based on the health hazards of smoking (one of the dimensions of the health belief model) are too simplistic. Other influences on the reason why a person smokes when they know its ill-effects need to be discovered and therein lies a particular challenge to health promoters. Acknowledgement-This study was funded by the Scottish Home and Health Department who accept no responsibility for any of the views expressed in this paper.
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1982. Smith R. A doctor’s guide to the facts and figures of unemployment. Br. Med. J. 291, lIO7-1111, 1985. Cook D. G. A critical view of the unemployment and health debate. The Statistician 34, 73-82, 1985. Hughes P. R. and Hutchison G. Changing characteristics of male unemployment flows, 1972-1981. Employment Gazette 365-368, 1986.
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P. 0. and Jones D. R. Stress and heart disease: evidence of associations between unemployment and heart disease from the OPCS Longitudinal Study. Postgrad. Med. J. 62,
797-799. 1986. 6. Charlton J. R. H., Batter R., Thakhore
A., Silver R. and Aristidou M. Unemployment and mortality: a small area analysis. J. Epid. Comm. Hlth 41, 107-103,
1987. 7. Moser K. A., Goldblatt
P. 0.. Fox A. J. and Jones D. R. Unemployment and mortality: comparison of the 1971 and 1981 longitudinal study census samples.
Br. Med. J. 294, 86-90,
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8. Linn M. W., Sandifer R. and Stein S. Effects of unemployment on mental and physical health. Am. J. Publ. Hlth 75, 502-506,
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9. Stern J. The relationship between unemployment, morbidity and mortality in Britain. Pop. Studies 37, 61-74, 1985. 10. Arber S. Social class, non-employment, and chronic illness: continuing the inequalities in health debate. Br. Med. J. 294, 1069-1073,
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11. Lee A. J., Crombie I. K., Smith W. C. S. and TunstallPedoe H. Alcohol consumption and unemployment among men: the Scottish Heart Health Study. Br. J. Addict. 85, 1165-1170, 1990. 12. Cullen J. H., Ryan G. M., Cullen K. M., Ronayne T. and Wynne R. F. Unemployed youth and health: findings from the pilot phase of a longitudinal study. Sot. Sci. Med. 25, (2), 133-146, 1987. 13. Wescott G. (Ed.) The effect of unemployment on the health of workers in a U.K. steel town: preliminary results. In Health PoIicy Implications-of Unemployment. WHO Regional Office, Copenhagen, 1985. 14. Cook D. G., Cummins R. O., Bartley M. J. and Shaper A. G. Health of unemployed middle-aged men in Great Britain. Lancer i, 129&1294, 1982. 15. Smith W. C. S., Tunstall-Pedoe H., Crombie I. K. and Tavendale R. Concomitants of Excess Coronary Deaths-major risk factors and lifestyle findings from 10,359 men and women in the Scottish Heart Health Study. Scott. Med. J. 34, 550-555, 1989. 16. Tunstall-Pedoe H., Smith W. C. S., Crombie I. K. and Tavendale R. Coronary Risk Factor and Lifestyle Variation across Scotland: Results from the Scottish Heart Health Study. Scott. Med. J. 34, 5X-560, 1989.
17. Janz N. K. and Becker M. H. The health belief model: a decade later. Hlth Educat. Q. 11, l-47, 1984. 18. Crombie I. K., Smith W. C. S., Kenicer M. B. and Tunstall-Pedoe H. Geographical variation in coronary heart disease mortality in Scotland. Hlth Bull. 44, 193-202,
1986.
19. Crombie I. K., Smith W. C. S., Irving J. H. and Tunstall-Pedoe H. D. Experience with general practitioner list as a sampling frame for a survey of cardiovascular risk factors. The Statistician 38, 25-31, 1989. 20. Smith W. C. S., Crombie I. K., Tavendale R., Irving J. M., Kenicer M. B. and Tunstall-Pedoe H. The Scottish Heart Health Study: objectives and development of methods. Hlth Bull. 45, 211-217, 1987. 21. OPCS. Classt~cation of Occupations (1980). HM Stationery Office, London, 1980. 22. Khosla T. and Lowe C. R. Obesity and smoking habits by social class. Br. J. Prev. Sot. Med. 26, 249-256, 1972.
23. Holme I., Helgeland A., Hjermann I., Lund-Larsen P. G. and Leren P. Coronary risk factors and socioeconomic status. Lancer ii,13961398, 1976. 24. Morris J. N. Social inequalities undiminished. Lancer i, 87-90, 1979. 25. Moser K. A., Fox A. J. and Jones D. R. Unemployment and mortality in the OPCS longitudinal study. Lancer ii,
1324-1329, i984. 26. OPCS. Social Survey Division. General Household Survey 198.2 HMSO, London, 1984. 27. Marmot M. G., Adelstein A. M., Robinson N. and
28. 29.
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31. 32.
Rose G. A. Changing social class distribution of heart disease. Br. Med. J. 2, 1109-1112, 1978. Rose G. and Marmot M. G. Social class and coronary heart disease. Br. Heart J. 45, 13-19, 1981. Heller R. F., Williams H. and Sittampalam Y. Social class and ischaemic heart disease: use of the male:female ratio to identify possible occupational hazards. J. Epid. Comm. Hlth 38, 198-202, 1984. Colledge M. and Hainsworth M. Death on the dole? the impact of unemployment on health. Med. Sot. 8, 15-22, 1982. Ho-Yen D. O., Spence V. A., Moody J. P. and Walker W. F. Why smoke fewer cigarettes? Br. Med. J. 284: 1905-1907, 1982. Wagstaff A. Unemployment and health: some pitfalls for the unwary. Hlth Trends 18, 79-81, 1986.
Sot. Sci. Med. Vol. 33, No. II, pp. 1309-1312, 1991 Printed in Great Britain. All rights reserved
CIGARETTE
SMOKING
AND EMPLOYMENT
STATUS
AMANDA J. LEE,* IAIN K. CROMBIE,WILLIAM C. S. SMITH and HUGH D. TUNSTALL-PEDOE Cardiovascular Epidemiology Unit, Ninewells Hospital and Medical School, Dundee DDl 9SY, U.K.
Abstract-The smoking habits and health kncwledge of the unemployed and the full-time workers were investigated in a cross-sectional study of over 10,000 men and women throughout Scotland. For both sexes (age range 40-59 years), the proportion of current smokers and ever smokers was found to be considerably higher among the unemployed. Only a small part of the difference could be explained by standardisation for social class. The unemployed smokers had began to smoke at an earlier age, with significantly more smoking whilst still at school. Amongst current smokers, the unemployed males reported smoking fewer cigarettes a day, whereas unemployed women smoked more than their full-time counterparts. The reported levels were confirmed by the biochemical measures of smoking; serum thiocyanate and expired air carbon monoxide levels. In contrast to their differences in smoking habit, the two groups were very similar in their knowledge of the hazards of smoking. Smoking habits among the unemployed reflect a complex interaction of financial and both current and previous social factors. Such relationships present a particular challenge to health promotion campaigns. Key words-unemployment,
smoking habits, health knowledge
INTRODUCTION
haviour [20] and health knowledge and behaviour. In addition, each subject underwent a physical examinIn recent years concern about the health of the ation and had a blood sample taken. unemployed has increased [l-4]. Several studies have Data on current employment status was catefound both a higher mortality [5-71 and a_ higher gorised into one of seven groups: full-time job, partmorbidity [8-lo] amongst this group when compared time job, unemployed seeking work, unemployed to those in full-time employment. Recent studies indicate that the unemployed drink more alcohol [ 111 because sick or disabled, housewife, wholly retired from employment and full-time student. Social class and smoke more cigarettes [12, 131 than those in was determined by present occupation using the employment. Further, this latter difference persists Office of Population Censuses and Surveys codes [21]. even after standardisation for age, social class and If the subject was currently unemployed, then social town of residence [14]. The Scottish Heart Health Study (SHHS) is a class was derived from their last known occupation. Married women were classified by their husbands cross-sectional survey of cardiovascular risk factors occupation. in representative samples of men and women Subjects were split into three groups on the basis throughout Scotland. Results concerning the major of their current smoking status: current cigarette risk factors and life-style variation across Scotland smokers, ex-cigarette smokers and ever smoked cigahave been published [15,16]. This paper contrasts the rettes. A current smoker was someone who had said smoking behaviour of the unemployed with that of that they now smoked cigarettes regularly or octhe full-time employed and it uses objective biochemicasionally. An ex-smoker was someone who used to cal tests to confirm self-reported levels of smoking. be a regular or occasional (usually less than one a Furthermore, differences between knowledge of the day) smoker. The ever-smoked group was the sum of health hazards of smoking and the actual smoking the previous two. During the physical examination, levels are compared. In doing this, the appropriateexpired carbon monoxide was determined using a ness of the health belief model [17] in the two groups Bedfont EC50 analyser. Serum thiocyanate was asis compared. sayed by a calorimetric method on a COBAS Bio centrifugal fast analyser. METHODS
The SHHS was designed to investigate the levels of Coronary Heart Disease (CHD) mortality and its geographic variation in Scotland [18]. A random sample of 10,359 men and women aged 4&59 years from 22 local government districts were used [19] representing 74% of those known to be resident at the time of the survey. A self completed questionnaire included questions on basic demographic details, occupational and employment status, smoking be*To whom correspondence and reprint requests should be addressed.
RESULTS
Overall, 81.9% of the men and 32.8% of the women were currently in full-time work although a further 31.1% of women were in part-time employment (Table 1). There were considerably more unemployed males than females possibly because some women regarded themselves as housewives rather than unemployed. Although data on seven employment categories were available, this paper concentrated on the full-time workers and the unemployed because of the small numbers in other categories.
1309
1310 Table
AMANDA J. LE et al.
I. Current employment status of the study participants
Full-time Part-time Unemployed (active) Unemployed (sick or disabled) Retired Student Housewife Overall N
Male
Female
81.9(4177) 0.8 (43) 9.4 (480)
32.8(1705) 31.1 (1618) 2.6(136)
5.8 (298)
3.2(165)
1.9(96) 0.1 (6) 5100
2.1 (111) 0.2 (9) 28.0(1453) 5197
Table 3. Smoking behaviour by social class and employment status standard&d for social class among men Male
% Current smokers
% % % %
both sexes, smoking is considerably more common among the unemployed (62.7% men and 50.7% of women) compared to those in full-time employment (35.4% men and 37.5% women). Among men, the proportions of ever-smoked are much closer. This difference is due to the lower proportion of ex-smokers among the unemployed (Table 2). However, this is not true for women where a considerably higher percentage of unemployed females have smoked at some time during their lives. The relatively small numbers of unemployed women indicate that this is a difficult group to define. A large number of the women classified themselves as either part-time workers or housewives. Further analysis showed that the smoking behaviour of these two groups resembled that of the full-time employed women: 37.3% of the part time women and 35.5% of the housewives were current smokers with the proportions of ever smokers being 57.2% and 56.3% respectively. It is known that both unemployment and smoking show strong social class gradients [22-251. Table 3 shows the expected trend in smoking by social class and also shows that for each social class group, the percentage of unemployed male current smokers was higher than their full-time counterparts. Furthermore, the prevalence of smoking among the unemployed in social classes I and II was higher than that of employed men from social classes IV and V. Due to the small number of unemployed women the female groups could not reliably be presented in this way. Direct standardisation for social class appears to have little effect on the proportions of male current and ex-smokers. Thus, only a small part of the higher smoking proportions among the male unemployed can be explained in terms of a differing social class structure. Further analysis showed no evidence of an interaction between smoking behaviour, district sampled and unemployment (data not presented). People who are destined to become unemployed later on in life may be socially different from the full-time workers. The percentage who began to smoke before reaching fifteen years old was signifiIn
Social class
Full-time
I, II IIIN IIIM IV, v
24.6 (382) 31.6(135) 42.7 (655) 45.5 (292)
52.0 (26) 53.3 (16) 62.5(150) 67.1 (104)
38.4 (1464) 36.0 (1490) 72.2 (2954) 29.8 (1197)
60.5 (296)*** 21.5(97)*** 80.6 (393j*** 20.7 (82)’
Current smokers’ Ex-smokers’ Ever smoked’ Never smoked’
*P < 0.05, l*P < 0.01, l**P < 0.001. aStandardised for social class.
cantly higher (P < 0.01) among the male unemployed (36.2%, n = 144) than among the employed males (24%, n = 714). Similarly, IO% (n = 10) of the unemployed females started smoking &fore this age compared to 6.8% (n = 67) of the full-time employed females. Furthermore, the unemployed males had slightly less years of education (average 10.1) than the employed males (average 11.2). The corresponding female figures were 10.6 and 11.5 years. Even though a greater percentage of the unemployed currently smoke, the question arises of whether they actually smoke more cigarettes? On average, the unemployed males smoked fewer cigarettes a day than the employed males. This finding was confirmed by lower serum thiocyanate and expired air carbon monoxide levels among the male unemployed (Table 4). In contrast, the unemployed females reported higher daily cigarette consumption which was substantiated by elevated thiocyanate and carbon monoxide levels. In contrast to the smoking levels, high proportions of both the unemployed and employed thought that by giving up smoking they could reduce their chances of having a heart attack (Table 5). Despite holding these views, the actual percentage of current smokers who had tried to smoke less in the preceding year was almost half the number who thought smoking harmful. The values were comparable for the two employment groups. DISCUSSION
This study has confirmed earlier reports on smoking and unemployment, but has also shed new light on the complexity of this association. As has been previously reported [ 13,261 a higher smoking prevalence among the unemployed of both sexes was found. Consistent with earlier reports [27-291 this study has found that smoking is more common in social
Table 2. Smoking behaviour by current employment status Female
Male % % % %
Current smokers Ex-smokers Ever smoked Never smoked
Unemployed
Full-time
Unemployed
Full-time
Unemployed
35.4 (1447) 35.9 (1496) 71.3 (2973) 28.7 (1200)
62.7(301)*‘* 20.2 (97)‘** 82.9 (398)“. 17.1 (82)**
37.5 (639) 20.3 (346) 57.8 (985) 42.2 (719)
50.7 (69)’ 22.8 (31) 73.5 (loo)**’ 26.5 (36)’
‘P < 0.05, ‘*P < 0.01, l**f r: 0.001 Note: No smoking data was available for a small number of subjects.
1311
Cigarette smoking and employment status Table 4. Cigarette consumption
and biochemical measures of smoking of current smokers by emulovmcnt status Female
Male
Mean no. cigs/day Mean serum thiocyanate (8moVl) Mean expired air carbon monoxide (ppm)
Full-lime
Unemployed
Full-time
Unemployed
21.1 (10.3) 120.3 (39.2)
19.9 (9.5) 119.1 (39.7)
16.8 (7.7) 129.6(47.1)
18.1 (6.2) 140.5 (38.6)
Zl.S(l3.6)
22.9 (13.1)
24.5 (14.1)
22.4(12.4)**
Mean (SD). l*P < 0.01.
Table 5. Health knowledge and behaviour of current smokers by employment status Male
Q: Do you think that stopping smoking may reduce your chance of having a heart attack? % Answering YES Q: Over the last year, have you tried to smoke fewer cigarettes? % Answcrina YES
Female
Full-time
Unemployed
Full-time
Unemployed
92.0(1318)
86.2 (250)
92.4 (574)
92.8 (64)
49.1(712)
48.0 f 142)
61.5 (384)
62.3 (43)
classes IV and V than classes I and II. As a higher proportion of the unemployed come from the lower social classes [30], the male smoking data were standardised for social class. This standardisation did not alter the higher levels of smoking among the unemployed, and has been reported elsewhere [12, 141. An additional finding was that more of the unemployed began smoking before the age of fifteen. This suggests that there may be other more subtle social differences between the two groups than simply social class since social class is based on occupation only. The consequences of unemployment on smoking behaviour are difficult to predict. On the one hand, it might be thought that the financial consequences of job loss would lead to stopping smoking or reducing consumption. On the other hand, the enhancement of stress that unemployment entails could cause a boost in consumption and/or expansion in the numbers who smoke. Nevertheless, the proportions who gave up smoking within the previous 5 years were similar among the employed and the unemployed (data not presented). We also found that the unemployed men actually smoked fewer cigarettes than the full-time employed males. These differences in the average number of cigarettes smoked were consistent across the social groups for both sexes. Changes in smoking habit can be accompanied by a compensatory increased inhalation effect [31]; such an effect would be seen by higher levels of the biochemical indicators. However, we found no evidence of this since our results were confirmed by lower thiocyanate and carbon monoxide levels. Validation of self-reported smoking behaviour with smoking biochemistry is an important point and one which is rarely reported. In contrast to the men, women out of work had higher consumption levels (again validated by the smoking biochemical indicators) when compared to the full-time employed females. Using the health belief model approach [17], there is an obvious difference between what people believe
and what they do with regard to smoking. Almost all of the smokers knew that giving up smoking would decrease their risk of a heart attack. However, the actual percentages who had tried to reduce their consumption in the previous twelve months was low. These limited data further demonstrate that the unemployed smokers were similar to the employed smokers in their knowledge of the hazards of smoking and in their recent attempts to stop. Due to the nature of unemployment, there may be a time lag between job loss and changes in health behaviour [32]. However, one limitation to the present study was that no information was available on the length of time a person had been out of work. There is a need for prospective studies in this field. In conclusion, the smoking habits of the unemployed reflect a complex interaction of both financial and social factors. As we found no difference in the health knowledge of the effects of smoking between the two employment groups, this suggests that education campaigns based on the health hazards of smoking (one of the dimensions of the health belief model) are too simplistic. Other influences on the reason why a person smokes when they know its ill-effects need to be discovered and therein lies a particular challenge to health promoters. Acknowledgement-This study was funded by the Scottish Home and Health Department who accept no responsibility for any of the views expressed in this paper.
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