ResearchPublications

As described by Healthy People 2020 “social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship and age, that affect a wide range of health, functioning and quality-of-life outcomes and risks.”3 Socioeconomic status, the focus of this chapter, relates to each of the five Healthy People 2020 areas of social determinants of health: economic stability; education; social and community context; health and health care; and neighborhood and built environment.

As the chapter describes, there is very strong evidence showing that educational attainment is closely linked with tobacco use across the continuum; this evidence is strongest for white and black populations. Small sample sizes and lack of focus on acculturation and nativity make conclusions regarding the relationship between education and tobacco use for other racial/ethnic groups less firm. Educational gradients appear to exist among LGBT populations as well, although fewer studies have examined this population group. Education is closely associated with cognition and social capital and also helps determine other socioeconomic factors, such as occupation, income and wealth, and type of neighborhood. As Link and Phelan have said, “social factors such as socioeconomic status…are likely ‘fundamental causes’ of disease.” Given the consistent association with tobacco use, and strong theoretical plausibility, this statement may be extended to say that social factors such as low educational attainment may be a “fundamental cause” of tobacco use.

Diverse efforts to increase educational attainment within and across different racial/ethnic groups may contribute to reducing tobacco use. Population-wide strategies that increase educational attainment may have considerable multiplier effects for improving population health and reducing TRHD over the long term. These efforts will be especially important for individuals and population groups with lower overall levels of educational attainment. As of 2015, adults with a 4-year college degree or greater were the only educational group to have reached the Healthy People 2020 target of reducing cigarette smoking by adults to 12%. To reach the Healthy People 2020 target, smoking must decrease among all educational groups, but at a faster rate among individuals with lower educational levels. Policy interventions that broadly improve educational attainment may contribute to this effort. Many studies also show a strong inverse association with income, regardless of the measure of income used. Income could be linked to tobacco-related outcomes through a variety of indirect pathways. For example, lower income might be associated with higher levels of psychosocial stress, leading to tobacco use as a perceived coping behavior, or with occupational exposure to SHS. Those with less income may live in communities where smoking is more normative or where tobacco advertising or the availability of tobacco products is more prevalent than in other communities.

Studies that examine tobacco use along the life course tend to find an association between parental education and occupation, and tobacco use among the offspring in adulthood. Causal pathways between life-course SES and measures along the tobacco use continuum in adulthood are inherently indirect and therefore difficult to measure. Parental education could affect many factors, such as parent–child relationships, which influence adolescent smoking and in turn adult smoking. Early-life SES could also influence trajectories for later-life education, occupation, income, wealth, and neighborhood SES and could subsequently influence tobacco outcomes through the pathways previously described for these measures.