Abstracts

INTRODUCTION

The smoking habit is a risk factor for ischemic heart disease, cerebrovascular disease, lower respiratory tract infections, chronic obstructive pulmonary disease, respiratory system cancer and tuberculosis, among others¹1. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Office on Smoking and Health. The health consequences smoking - 50 years of progress: a report of the Surgeon General. Atlanta: U.S. Government Printing Office; 2014.. Nowadays, tobacco is the most used drug in the world, responsible for approximately 5.4 million deaths a year, out of which 50% occur in mid and low-income countries²2. World Health Organization (WHO). Tobacco Control: Country Profiles. Genebra: WHO; 2003.. The habit of smoking cigarettes can be associated with 25% of cerebrovascular diseases, 30% of deaths caused by malignant neoplasms, 45% of heart diseases and 85% of respiratory diseases³3. BRASIL. Instituto Nacional do Câncer. Programa Nacional de Controle do Tabagismo [Internet]. Disponível em: http://www1.inca.gov.br/tabagismo/frameset.asp?item=programa&link=introducao.htm. (Acessado em 12 de fevereiro de 2014)
http://www1.inca.gov.br/tabagismo/frames... . Additionally, passive smoking is the 3^rd major preventable cause of death in the world, after the habit of smoking cigarettes and excessive alcohol consumption⁴4. World Health Organization (WHO). WHO Framework Convention on Tobacco Control: why is it important? Genebra; 2012. [Internet] Disponível em: http://www.who.int/features/qa/34/en/. (Acessado em 12 de fevereiro de 2014)
http://www.who.int/features/qa/34/en/... . In Brazil, it is estimated that about 200 thousand deaths a year are associated with the smoking habit⁵5. Brasil. Ministério da Saúde. Instituto Nacional de Câncer. O cigarro brasileiro: análises e propostas para redução do consumo. Rio de Janeiro: INCA; 2000..

In 2008, approximately 3.3 billion individuals, that is, more than half of the world population, lived in cities. In 2030, it is estimated that around 5 billion people will live in urban areas. Therefore, globally, the future population growth will take place in the cities, which are already densely populated⁶6. The Department of Economic and Social Affairs of the United Nations (DESA). World urbanization prospects. The 2007 revision. New York: DESA; 2008.. In Brazil, the proportion of people living in urban areas increased from 31.3%, in 1940, to 84.3%, in 2011⁷7. Brito F, Souza J. Expansão urbana nas grandes metrópoles: o significado das migrações intrametropolitanas e da mobilidade pendular na reprodução da pobreza. São Paulo Perspec 2005; 4: 48-63.; consequently, urban centers will have most of the smokers in the country.

Recent studies have shown that the physical and social surroundings (PSS) of the household are associated with the smoking habit⁸8. Chuang YC, Li YS, Wu YH, Chao HJ. A multilevel analysis of neighborhood and individual effects on individual smoking and drinking in Taiwan. BMC Public Health; 2007; 7: 151. ^{, 9}9. Adams RJ, Howard N, Tucker G, Appleton S, Taylor AW, Chittleborough C, et al. Effects of area deprivation on health risks and outcomes: a multilevel, cross-sectional, Australian population study. Int J Public Health 2009; 54(3): 183-92.. Some of these studies suggest that such an association can be independent from individual socioeconomic status¹⁰10. Ahern J, Galea S, Hubbard S, Syme S. Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior. Drug Alcohol Depend 2009; 100(1-2): 138-45.

11. Cubbin C, Sundquist K, Ahlén H, Johansson SE, Winkleby MA, Sundquist J. Neighborhood deprivation and cardiovascular disease risk factors: protective and harmful effects. Scand J Public Health 2006; 34(3): 228-37.

12. Datta G, Subramanian SV, Colditz GA, Kawachi I, Palmer JR, Rosenberg L. Individual, neighborhood, and state-level predictors of smoking among US Black women: a multilevel analysis. Soc Sci Med 2006; 63(4): 1034-44. ^{- 13}13. Diez-Roux AV, Nieto FJ, Mutaner C, Tyroler HA, Comstock GW, Shahar E, et al. Neighborhood environments and coronary heart disease: a multilevel analysis. Am J Epidemiol 1997; 146(1): 48-63.. In Brazil, the influence of PSS of the neighborhood and the habit of smoking cigarettes has been little analyzed, and, to our knowledge, there are no population-based epidemiological studies in major urban centers on the subject.

This study aims at examining and quantifying the association between perception of the neighborhood and smoking habit among adults living in the metropolitan rea of Belo Horizonte, Minas Gerais.

METHODS

Data source and population

The data source for this study was the Health Survey from the Metropolitan Region of Belo Horizonte (RMBH), conducted from May to July, 2003. The survey sample was designed to produce estimates of the non-institutionalized population aged 10 years old or more, living in the 20 cities that composed the RMBH. This is a two-stage probability cluster sample. The census sectors from the Brazilian Institute of Geography and Statistics (IBGE) were used as the primary selection unit, and the sampling unit was the household. The estimated loss in the sampling calculation accounted for 20%. All of the people living in the household aged 10 years old or more were eligible for a face to face interview. Out of the 7,500 sample households, 5,922 (79%) participated in the survey. More details are demonstrated in another publication¹⁴14. Lima-Costa MFF. A saúde dos adultos na Região Metropolitana de Belo Horizonte: um estudo epidemiológico de base populacional. Belo Horizonte: Núcleo de Estudos em Saúde Pública e Envelhecimento, Fundação Oswaldo Cruz, Universidade Federal de Minas Gerais; 2004.. For this study, all of the participants in the health survey aged 20 years old or more were selected.

Response variable

The smoking habit was defined by the following question: "Which of the following sentences defines your habits regarding cigarettes better?", with six alternatives: (1) never smoked; (2) never smoked 100 cigarettes in a lifetime; (3) already smoked 100 cigarettes in a lifetime, but quit it; (4) less than 20 cigarettes a day; (5) from 21 to 40 cigarettes a day; and (6) more than 40 cigarettes a day. Those who gave positive answers to options 1 and 2 were classified as non-smokers; the ones who gave a positive response to option 3 were considered to be former smokers; and current smokers were the ones who gave positive responses to the other options. Questions concerning the use of cigarettes used in this study were translated to Portuguese from the questionnaire of the National Center for Health Statistics (NCHS)¹⁵15. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Center for Health Statistics (NCHS). Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994. Series 1: programs and collection procedures. Washington: NCHS; 1994..

Explanatory variables

The main explanatory variable was the perception of the neighborhood, categorized as satisfactory and unsatisfactory. These categories were built based on the responses (yes/no) to the following questions: (1) "Do you feel comfortable in the neighborhood where you live, that is, do you feel at home?", (2) "Are you satisfied about how the block where you live is taken care of?"; (3) "Is your neighborhood a good place to live?"; (4) "Are you proud to tell others about the place where you live?"; (5) "Do your neighbors help each other?"; (6) "Do children and teenagers in your neighborhood treat adults with respect?"; and (7) "Is your neighborhood a good place for children to play and to raise adolescents?". More than three positive responses (yes) were defined as a satisfactory perception of the neighborhood. Three or fewer positive responses were defined as a less pleasant perception of the neighborhood. This variable was built by the authors for being the mean point of the seven possible responses, after factorial analysis.

Other explanatory variables constituted four domains: (1) socioeconomic and demographic characteristics (age, sex, marital status, time of household in RMBH, schooling years, filiation to a private health insurance plan and current job); (2) health behaviors (excessive alcohol consumption, physical activities at leisure times and daily intake of fruits, vegetables or greens in the past 30 days); (3) history of medical diagnosis for diseases and chronic conditions. Excessive alcohol consumption was defined by the intake of 5 or more doses in a single occasion in the past 30 days¹⁶16. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System [Internet]. 2001. Disponível em: http://www.cdc.gov/brfss/. (Acessado em 15 de fevereiro de 2014).
http://www.cdc.gov/brfss/... . Physical activities during leisure time were defined by the weekly frequency, in the past 90 days, of activities of any intensity for 20 to 30 minutes. The consumption of greens, fruits and vegetables was defined by the daily intake, regardless of the amount, in the past 30 days. The condition of having one or more chronic diseases was defined by the question "Has any doctor ever said you have", considering the following diseases or chronic conditions: arthritis, cancer, hypertension, asthma/bronchitis, diabetes, angina, infarction, another heart disease, stroke, chronic kidney disease and depression.

Statistical analysis

The non-adjusted data analysis was based on the χ² test for comparisons between frequencies, and on the analysis of variance for comparisons between means. The multivariate analysis was based on odds ratio (OR) and 95% confidence intervals (95%CI), estimated by multinomial logistic regression. The main explanatory variable was built based on the studied literature and on the factorial analysis of the responses in the survey that originated this study. All of the variables that presented associations with the smoking habit lower than 20% (p < 0.20) in the non-adjusted analysis were included in the logistic model; the ones who had associations with the smoking habit lower than 5% (p < 0.05) remained in the final multivariate model. The condition of the respondent (the person or a substitute) was at first considered as a confounding variable in the study, being maintained in the final model. Analyses were conducted with the software Stata 10.0 (Stata Corporation, College Station, Texas). The survey (svy) procedure was used for population surveys with complex samples, which considers the design effect¹⁷17. Lê TN, Verma VK. Demographic and Health Surveys (DHS). DHS Analytical Reports. An Analysis of Sampling Designs and Sampling Errors of the Demographic and Health Surveys. Calverton: Macro International Inc; 1997., the weight of the individuals in the sample and the household cluster.

The Health Survey in the Metropolitan Region of Belo Horizonte was approved by the Ethics Committee from the Research Institute René Rachou, in Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais (Report n. 011, from 20/12/2001).

RESULTS

Out of the 13,636 participants of the Heath Survey in the RMBH aged 20 years old or more, 12,129 (88.9%) had complete information for all of the study variables and were included in this analysis. Participants and non-participants were similar (p < 0.05) with regard to sex, age, schooling years, smoking habit and perception of the neighborhood.

Concerning the habit of smoking cigarettes, 65.1% of the participants had never smoked, 14.1% were former smokers and 20.8% were current smokers. Satisfaction about the neighborhood was prevalent in the studied population (74.5%).

Among participants, mean age was of 40.5 years old, and the age group between 20 and 29 years old was prevalent (29.9%), as well as the female gender (54.3%) with lower schooling (44.4% had not completed elementary school or were illiterate); as observed in Table 1.

Table 2 shows the results of the univariate analysis of the association between perception of the neighborhood and socioeconomic and demographic characteristics with the smoking habit. The perception of the neighborhood, age, sex, marital status, time of household in the RMBH, schooling years, filiation to a private health insurance plan and current job presented statistically significant associations with the smoking habit. The excessive alcohol consumption, physical activities during leisure time, the daily intake of vegetables, fruits and greens and the condition of having at least one chronic disease presented statistically significant associations with the smoking habit.

The final results of the multivariate analysis (Table 3) show that the perception of the neighborhood, age group and sex presented statistically significant associations with the smoking habit. In comparison to those who never smoked, former smokers were less satisfied about their neighborhood, mostly older men. In comparison to those who never smoked, current smokers were less satisfied about their neighborhood, mostly men aged between 30 and 59 years old.

DISCUSSION

The results in this study indicate the association between the least satisfactory perception of the neighborhood and being a smoker in the RMBH. This association persisted even after adjustments by socioeconomic and demographic characteristics, health-related behaviors and self-reported health conditions.

In general, these results are in accordance with studies conducted in cities from high-income countries, like Amsterdam, in the Netherlands, and Minneapolis, in the United States¹⁸18. Reijneveld SA. The impact of individual and area characteristics on urban socioeconomic differences in health and smoking. Int J Epidemiol 1998; 27(1): 33-40. ^{, 19}19. Patterson JM, Eberly L, Ding Y, Hargreaves M. Associations of smoking prevalence with individual and area level social cohesion. J Epidemiol Community Health 2004; 58(8): 692-7.. Some studies are conclusive with regard to the importance of the neighborhood for the habit of smoking cigarettes. An analysis conducted in London, England, used a multilevel model and reported that living in more vulnerable areas, in relation to the characteristics of the physical and social surroundings, would be related to the higher frequency of cigarette use and the habit of smoking cigarettes²⁰20. Giskes K, van Lenthe FJ, Turrell G, Brug J, Mackenbach JP. Smokers living in deprived areas are less likely to quit: a longitudinal follow-up. Tob Control 2006; 15(6): 485-8.. Besides, in Manchester, England, living in more vulnerable places with regard to physical and social surroundings was a predictive factor for the number of cigarettes smoked by the participants²¹21. Duncan C, Jones K, Moon G. Smoking and deprivation: are there neighbourhood effects? Soc Sci Med 1999; 48(4): 497-505.. More recently, a study conducted in several cities of France showed that the risk of being a smoker was comparatively higher in areas with lower income, even after individual factors were controlled (education, income, occupation)²²22. Chaix B, Chauvin P. Tobacco and alcohol consumption, sedentary lifestyle and overweightness in France: a multilevel analysis of individual and area-level determinants. Eur J Epidemiol 2003; 18(6): 531-8.. In Austin, in the United States, a study involving the afro-descendants showed that physical and social surroundings were more strongly associated with the habit of smoking cigarettes than the individual characteristics of the people living there²³23. Reitzel LR, Vidrine JI, Businelle MS, Kendzor DE, Cao Y, Mazas CA, et al. Neighborhood perceptions are associated with tobacco dependence among African American smokers. Nicotine Tob Res 2012; 14(7): 786-93.. A multilevel study conducted in cities from the count of Norfolk, in England, demonstrated that the higher the level of social vulnerability (worst socioeconomic status of the individuals and lower schooling), the higher the chances of these individuals being smokers²⁴24. Shohaimi S, Luben R, Wareham N, Day N, Bingham S, Welch A, et al. Residential area deprivation predicts smoking habit independently of individual educational level and occupational social class. A cross sectional study in the Norfolk cohort of the European Investigation into Cancer (EPIC-Norfolk). J Epidemiol Community Health 2003; 57(4): 270-6.. In another study, men living in Minneapolis, United States, who assessed their neighborhood as having more social cohesion, had less chances of being smokers¹⁹19. Patterson JM, Eberly L, Ding Y, Hargreaves M. Associations of smoking prevalence with individual and area level social cohesion. J Epidemiol Community Health 2004; 58(8): 692-7.. A multilevel study conducted in Adelaide, Australia, showed that aggregated features (indicator of relative socioeconomic disadvantage, obesity and quality of life) to the household area contribute with smoking, regardless of individual factors9. A recent study conducted in the Netherlands showed that people who live in more vulnerable areas presented less chances of abandoning the use of tobacco²⁰20. Giskes K, van Lenthe FJ, Turrell G, Brug J, Mackenbach JP. Smokers living in deprived areas are less likely to quit: a longitudinal follow-up. Tob Control 2006; 15(6): 485-8..

There are some limitations in this study. In sectional studies, it is not possible to establish temporal relationships or to ensure the asymmetry between exposure and event of interest. With regard to the response variable, our study did not measure the duration of cigarette use. Therefore, among smokers, some individuals have used cigarettes for very different periods of time. Yet, potential participants of this study, who would be the "inveterate smokers", may not have participated in the survey for having died or for being very ill and hospitalized. Also, a possible reason for the higher magnitude of the association for former smokers found in our study can be related to its cross-sectional design; therefore, it is possible that the group of former smokers is composed of individuals who recently abandoned the smoking habit, and others who did so a long time ago.

On the other hand, there are some positive aspects in this study, such as the sample size, the geographic scope of the third largest metropolitan region in the country and, in a recent literature review, the absence of a similar study in Brazil.

Our results suggest that programs against smoking should consider the importance of the physical and social surroundings of the neighborhood, which is an often neglected health determinant. Interventions on the physical and social surroundings of the neighborhood, which are not traditionally associated with the health field, may have a positive impact on the habit of smoking cigarettes²⁵25. Sallis JF, Owen N, Fisher EB. Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass; 2008. p. 465-86. ^{, 26}26. Sundquist J, Malmström M, Johansson SE. Cardiovascular risk factors and the neighbourhood environment: a multilevel analysis. Int J Epidemiol 1999; 28(5): 841-5..

CONCLUSION

The results can be associated with the unfavorable conditions of the most vulnerable physical and social surroundings of the neighborhood. Further studies should take place in Brazil to investigate other factors associated with the use of cigarettes, other than individual ones⁵5. Brasil. Ministério da Saúde. Instituto Nacional de Câncer. O cigarro brasileiro: análises e propostas para redução do consumo. Rio de Janeiro: INCA; 2000., in order to better understand this and other public health problems. Besides, public programs against smoking should consider the importance of the physical and social surroundings (PSS) of the neighborhood, which is an often neglected health determinant. Therefore, interventions on the physical and social surroundings of the neighborhood, which are not traditionally associated with the health field, may have a positive impact on behaviors and lifestyles, such as the habit of smoking cigarettes.

REFERENCES

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