Associations of Smoking Prevalence with Individual and Area-Level Social Cohesion

1. Associations of Smoking Prevalence with Individual and Area-Level Social Cohesion Joän M. Patterson, Ph.D. Lynn E. Eberly, Ph.D. University of Minnesota School of Public Health Yingmei Ding, M.D., M.S. Margaret Hargreaves, M.P.P. Hennepin County Community Health Department Minneapolis, MN

2. Abstract Data from a 1998 telephone survey of 10,062 adults, stratified by 19 geographic areas in an urban county, were used to examine the relationship between cigarette smoking and area-level measures of social cohesion, neighborhood safety, and home safety after adjusting for concentrations of poverty and low education. Both area-level and individual-level social cohesion were associated with lower likelihoods of smoking. Similar models were obtained for neighborhood safety and home safety. Introduction Individual factors associated with smoking tobacco among adults in the U.S. have been well specified. More recent studies have begun to focus on area-level risk factors associated with smoking, such as neighborhood concentrations of poverty or low education. However, very few studies have emphasized positive area-level characteristics that may protect residents from smoking. Area-level social cohesion, defined as “the extent of connectedness and solidarity among groups in society,” may serve such a protective function by 1) promoting more rapid diffusion of health information, 2) increasing the likelihood that norms of healthy behavior are adopted, and/or 3) exerting social control over deviant health-related behavior. Study Hypothesis: Personal social cohesion and residence in a geographic area with a collective sense of social cohesion are both negatively associated with smoking among adults. Methods The study sample was derived from a population-based survey (SHAPE) of a random sample of adults (>18 yrs), stratified by 19 geographic areas, who lived in Hennepin County, MN in 1998. Telephone interviews were conducted with 5,256 men and 4,806 women (90.1% response rate). 2 7 5 11 3 1 8 4 9 10 6 Hennepin County, Minnesota

3. Methods • Social Support Index (SSI) • (4-pt Likert agree-disagree scale) • People can depend on each other in this community • Living in this community gives me a secure feeling • People here know they can get help from the community if they are in trouble • This is not a very good community to bring children up in • There is a feeling in this community that people not get too friendly with each other • If I had an emergency, even people I do not know in this community would be willing to help • Individual Measures • Current smoking (yes/no) • Social cohesion (based on SSI score, 6 – 24) • Neighborhood safety (yes/no) • Home safety (yes/no) • Demographic characteristics (gender, age, education, income, race, health insurance) • Area-level Measures (for each of 19 geographic areas) • Social cohesion (Statistical mean of all respondents’ scores on SSI) • Neighborhood safety (Statistical mean of all yes/no responses) • Home safety (Statistical mean of all yes/no responses) • Concentration of poverty (<150% of 1996 FPL) • (hi = > 20%; medium = 10-19%; low = < 10% of residents in an area) • Concentration of low education (< high school) • (high = > 4.7% (mean + 1 SD); medium = 4.4 – 4.6%; high = < 4.4%) • Statistical Methods • Logistic regressions to explore the associations of individual-level and area-level characteristics and their interactions with the probability of smoking • Created unadjusted, partially adjusted, and fully adjusted results for 3 logistic regression models of social cohesion, neighborhood safety and home safety • Fit a population-averaged (marginalized) version of a multilevel (hierarchical) logistic model for binary outcomes with within-cluster correlations (19 geographic areas) • Predicted smoking probabilities computed from the final models and summarized within selected demographic groups • Analyses used probability sampling weights and geographic clustering design – results represent the target adult population in Hennepin County

4. Results • Range across • Overall 19 geographic areas • 21.2% smoked 16.1% - 32.7% • 14.0% felt unsafe in their neighborhoods 2.7% - 43.1% • 3.7% felt unsafe at home 0.9% - 12.0% • Social cohesion mean = 17.99 (SD = 2.58) 15.4 - 19.21 Model 1: Social Cohesion and Smoking In the unadjusted model, area-level social cohesion decreased the likelihood of smoking by 21% for each 1 point increase in the area-level social cohesion score. It remained negatively associated with smoking in both the partially adjusted and fully adjusted models. Individual-level social cohesion showed an additional negative association with smoking. Model 2: Neighborhood Safety and Smoking Area-level (but not individual-level) neighborhood safety was negatively associated with smoking. In the fully adjusted model, 1% higher area-level safety reduced the odds of an individual smoking by 1%. Each 1-point increase in individual-level social cohesion reduced the risk of smoking by 22%.

5. Model 3: Home Safety and Smoking Area-level (but not individual-level) home safety was negatively associated with smoking. 1% higher area-level home safety was associated with a reduced odds of smoking of 4%. Individual- and area-level social cohesion under different combinations of individual-level characteristics The overall probability of smoking is greater under circumstances of greater deprivation – that is, less income and less education, even though the pattern is similar. Area-level Social Cohesion 1st Quartile Median 3rd Quartile Family income: > 400% of FPL Individual education = Bachelor’s Probability (current cigarette smoker Probability (current cigarette smoker Family income: < 200% of FPL Individual education = high school 1st Quartile Median 3rd Quartile Individual Social Cohesion 1st Quartile Median 3rd Quartile Individual Social Cohesion Discussion We found that area-level social cohesion and safety measures have important associations with smoking. These findings are consistent with the growing recognition that individual risk behaviors, like smoking, occur in and are shaped by one’s social context. Just as individual social support has been promoted to enhance health, these results challenge us to consider strategies to promote social cohesion at the community level as a way to improve health behaviors and outcomes.