In the current study, we describe the association between smoking habits and a broad set of social characteristics in the ethnically diverse population of Israel.
We found that current smokers were less affluent than never smokers. Lower SES has been associated with higher smoking rates in other developed countries as well [8, 17, 18]. Multiple factors may explain the socio-economic gradient in smoking, including lower awareness of the health hazards of smoking, higher nicotine dependence and less supportive social environment [19]. We found that the association between smoking status and education or socio-economic parameters differed by gender. While unemployed men or men with lower educational level were more likely to be smokers, among women we found a positive association between cigarette smoking and income level, and the association between smoking status and educational levels was less clear. Similar gender-related differences in the association between income and educational level and smoking status have been reported in some southern European countries [20–22]. Possible explanations include failing of social barriers which traditionally prevented female smoking, association of female smoking with higher gender empowerment, using smoking for body weight control, and the effect of selective smoking advertising directed towards women [23–26].
We found that family status other than being married was associated with higher likelihood of current smoking, especially among women. Higher likelihood of current smoking among divorced and widowed people was reported also in the US population. The authors suggested that lack of social support may explain this finding [27]. Nevertheless, the greater likelihood of current smoking among single women found in our study suggests that other factors may also play a role, such as lack of incentives to stop smoking (e.g. no need to protect other family members sharing the same household from the ill effects of smoking).
Men who belong to the Arab minority group and male immigrants were more likely to be current smokers than Jewish men who were born in Israel, while opposite trends were found among women. The smoking rates among Arab men and women in our study were similar to those reported in other Middle-Eastern and North-African countries [28]. Gender difference in the association between ethnicity and smoking rates were also described in the African American and white population in the United States, where cigarette smoking was more common among African American men than among white men, while the opposite trend was observed among women [29]. Previous data from periodic telephone surveys in Israel showed that between 2000 and 2008 smoking rates decreased by 3.5 % among adult Jewish men, while an increase of 6.5 % was reported among Arab men [13]. A recent study also showed that Arab male smokers have low intention to stop smoking, with 60 % of current smokers being in the pre-contemplation phase [30].
Since the early 1990s, Israel has absorbed a large immigrant population from the former Soviet Union countries. The rates of current cigarette smoking among men in those countries is very high, ranging from 43 % in Moldova to 65 % in Kazakhstan, while cigarette smoking is relatively uncommon among women in these countries (2.4-15.5 %) [31].
The differences in the age of smoking initiation between Arabs, Israeli-born Jews and immigrants to Israel were previously described [14].
Despite a constant decline in cigarette smoking rates with increasing year of birth among men, there was a concomitant disturbing trend toward younger age at smoking initiation with increase in birth year in both gender groups. Our results confirm a previous report showing a trend of younger age at smoking initiation among young adults recruited to mandatory service in the Israel Defence Force [15]. Data from the US show that the age at smoking uptake remained stable across birth cohorts among men, while among women, the age at smoking initiation declined and is similar to men in recent birth cohorts [32].
This study is cross-sectional design, and thus one should be cautious in making inferences on causal associations. In addition, the information on smoking habits was based on self-reports and was not validated by testing cotinine blood or urine levels. Thus, possible differential misclassification by gender, ethnicity and other characteristics cannot be excluded. We also cannot exclude a recall bias related to age at smoking initiation, although the short-term reliability of this information tested in the Israeli population was good for both sexes [33]. However, the study sample, which was both large and representative, and the high consent rate provide high precision and external validity to our study results. The large set of social characteristics collected allowed us to study characteristics which are significantly and independently associated with smoking, after controlling for other closely related variables. With this respect, the current study differs from previous reports on smoking in Israel, that were either based on a selective population (e.g. soldiers recruited to mandatory military service in the Israel Defense Forces), or on data collected by land-line telephone interviews, with low consent rates. Such samples are prone to under-represent ultra-Orthodox Jews, Arabs, underprivileged populations, younger people and immigrants [13–15].
Implications to health policy
Tobacco control
Evidence show that effective tobacco control measures in the form of tobacco products taxation, smoke-free legislation and tobacco sale restriction to minors is effective in reducing disparities associated with smoking uptake and promote smoking cessation [34, 35]. Although Israel has adopted such policies [36], ineffective or selective enforcement of smoke-free and sale restriction legislation impairs its efficacy and may in fact increase health disparities associated with cigarette smoking. In fact, selective enforcement may partially explain the opposite time trends of cigarette smoking rates observed in Jewish and Arab men [13]. Thus, to address disparities related to cigarette smoking, effective enforcement of smoke-free and sale restriction legislation should be directed at population subgroups with high smoking rates, for example Arab communities.
According to the law on compulsory reporting of tobacco smoking-related health damages, the Israel Minister of Health issues annual reports with comprehensive information on smoking rates, smoking cessation activities, and smoking prevention legislation/regulations [37]. These public domain reports are discussed in the Israeli parliament and media.
Smoking prevention/cessation
Targeting smoking prevention/cessation efforts at disadvantaged populations is considered a major means to reduce health disparities. Nevertheless, smoking cessation media campaigns were found less effective in motivating cessation attempts and smoking abstinence among people with lower educational level [38]. People from low-income groups were also found less likely to participate in smoking cessation interventions [39], to adhere to such interventions, to stop smoking and maintain long-term smoking abstinence compared to people of higher socioeconomic position [40, 41]. While economic incentives proved promising in motivating smokers to stop smoking, they were mostly implemented at worksites and in general included people from more advantaged groups [42, 43]. The feasibility and efficacy of such interventions among people who are socially disadvantaged have yet to be determined.
Culturally sensitive interventions targeted at minority adolescents in the US were effective in reduction of smoking uptake but not in increasing smoking cessation [44]. Recently, a feasibility study tested the effect of web-based intervention aimed to increase knowledge and reduce cigarette and nargila smoking among Arab university students, of whom one-fifth were smokers. The intervention was well-accepted, increased the proportion of students in the contemplation phase, but was not associated with cigarette smoking cessation after 1 month [45]. We are not aware of other studies evaluating the efficacy of smoking prevention/cessation interventions among low SES groups, immigrants and ethnic minority groups in Israel.
To reduce disparities related to cigarette smoking, smoking prevention/cessation programs should be culturally-congruent and address the different motives and needs among cigarette smokers who differ by ethnicity, immigration status, socioeconomic position, sex and cultural background. Smoking prevention/cessation programs and policy changes must be properly evaluated in these diverse population subgroups, in order to assess their effectiveness in reducing disparities related to cigarette smoking.
Systematic collection of up-to-date information on smoking history, cessation attempts and methods, integrated in the primary care electronic health record, using adequate alerts and decision rules, may be effective in increasing the proportion of smokers who receive advice to stop smoking and effective cessation intervention.
