Surveillance and Health Services Research, American Cancer Society, 250 Williams Street NW, Atlanta, GA 30303, USA.
College of Global Public Health, New York University, 726 Broadway, New York, NY 10012, USA; Department of Population Health, New York University School of Medicine, 227 East 30th Street, 7th floor, New York, NY 10016, USA.
Prev Med. 2020 Feb;131:105957. doi: 10.1016/j.ypmed.2019.105957. Epub 2019 Dec 17.
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.
20 世纪 80 年代末，巴西是一个中低收入国家（LMIC），当时该国在国家收入和性别平等快速增长的情况下实施了一项强有力的国家烟草控制计划（NTCP）。我们评估了 1989 年至 2013 年期间按教育程度划分的吸烟流行率变化，并将这些变化与吸烟教育不平等趋势相关联。数据来自四项全国代表性的横断面调查（1989 年，n=25298；2003 年，n=3845；2008 年，n=28938；2013 年，n=47440，年龄 25-69 岁）。我们分别为男性和女性估算了吸烟流行率的绝对（不平等斜率指数，SII）和相对（相对不平等指数，RII）教育不平等。此外，还按出生队列进行分层分析，以评估代际差异。1989 年至 2013 年间，所有教育群体的吸烟率均显著下降，但在受教育程度较高的女性中下降更为明显。因此，1989 年至 2013 年间，女性吸烟的绝对和相对教育不平等均扩大了三倍（RII：1.31 至 3.60，SII：5.3 至 15.0），但女性吸烟的绝对不平等主要扩大到 2003 年（SII：15.8）。相反，在男性中，只有在相对意义上，高教育群体的吸烟率下降更为明显。因此，1989 年至 2013 年间，男性吸烟的相对教育不平等扩大（RII：1.58 至 3.19），但主要扩大到 2008 年（3.22），而男性吸烟的绝对平等在 24 年期间保持不变（1989 年：21.1 与 2013 年：23.2）。与年龄较大的队列相比，较年轻的队列（出生于 1965 年及以后）在可比年龄时的吸烟相对不平等更大，尤其是在最年轻的女性队列（出生于 1979-1988 年）中。我们的结果表明，在中低收入国家实施人口烟草控制工作的同时，社会快速发展，社会经济地位较低的年轻群体，尤其是女性，可能更容易受到吸烟率差异上升的影响。
