The Greek smoking epidemic from a life-course perspective.

BACKGROUND: Smoking rates in Greece are the highest recorded among OECD countries, but the historical and life-course evolution of smoking patterns is largely unknown. The present paper addresses this gap. METHODS: We produce nationally representative life-course trajectories of smoking and related mortality of eight generations of Greek men and women. We estimate the smoking-mortality correlation conditional on several confounders and project the estimates forward. RESULTS: We show that smoking prevalence among Greek men has plateaued at >60% for all but the youngest generation. For women, smoking prevalence is relatively lower, lags by several generations and follows a hump-shaped pattern. Smoking-attributable mortality is currently peaking for men (nearing 40% of total deaths) and is rising for women. We estimate that it takes ~20 years of smoking to maximize the smoking-mortality correlation (at 0.48 for men and 0.32 for women). Based on this estimation, we forecast that mortality rates will begin falling within the current decade. CONCLUSIONS: The breadth of the Greek smoking epidemic has been high by international standards, reflecting the ineffective tobacco control efforts in the country. While smoking popularity fell during the Great Recession, policy vigilance is necessary to prevent a relapse once the economy recovers.

A Novel Indicator of Life-Course Smoking Prevalence in the United States Combining Popularity, Duration, Quantity, and Quality of Smoking.

OBJECTIVES: To develop a smoking indicator that combines the popularity and duration of smoking and the quantity and quality of consumed cigarettes, factors that vary dramatically over time and across generations. METHODS: We used retrospective reports on smoking behavior and a time series of cigarette tar yields to standardize nationally representative life-course smoking prevalence rates of 11 generations of US men and women, spanning 120 years. For each generation and gender, we related the standardized data with the corresponding rates of smoking-attributable mortality. RESULTS: Our indicator suggests that US cigarette consumption spread, peaked, and contracted faster than commonly perceived; predicts a significantly stronger smoking-mortality correlation than unadjusted smoking prevalence; and reveals the emergence of a delay (by up to 8 years) in premature death from smoking that is consistent with increasing population access to effective treatments. In fact, we show that, among recent cohorts, smoking health-risk exposure is at a historic low and will account for less than 5% of deaths. CONCLUSIONS: Relative to unstandardized measures, our novel, standardized indicator of smoking prevalence describes a different history of smoking diffusion in the United States, and more strongly predicts later-life mortality.

Is Smoking Behavior Culturally Determined? Evidence from British Immigrants.

We exploit migration patterns from the UK to Australia and the US to investigate whether a person's decision to smoke is determined by culture. For each country, we use retrospective data to describe individual smoking trajectories over the life-course. For the UK, we use these trajectories to measure culture by cohort and cohort-age, and more accurately relative to the extant literature. Our proxy predicts smoking participation of second-generation British immigrants but not that of non-British immigrants and natives. Researchers can apply our strategy to estimate culture effects on other outcomes when retrospective or longitudinal data are available.

Smoking behavior of Mexicans: patterns by birth-cohort, gender, and education.

OBJECTIVES: Little is known about historical smoking patterns in Mexico. Policy makers must rely on imprecise predictions of human or fiscal burdens from smoking-related diseases. In this paper we document intergenerational patterns of smoking, project them for future cohorts, and discuss those patterns in the context of Mexico's impressive economic growth. METHODS: We use retrospectively collected information to generate life-course smoking prevalence rates of five birth-cohorts, by gender and education. With dynamic panel data methods, we regress smoking rates on indicators of economic development. RESULTS: Smoking is most prevalent among men and the highly educated. Smoking rates peaked in the 1980s and have since decreased, slowly on average, and fastest among the highly educated. Development significantly contributed to this decline; a 1 % increase in development is associated with an average decline in smoking prevalence of 0.02 and 0.07 percentage points for women and men, respectively. CONCLUSION: Mexico's development may have triggered forces that decrease smoking, such as the spread of health information. Although smoking rates are falling, projections suggest that they will be persistently high for several future generations.

Dying for a smoke: how much does differential mortality of smokers affect estimated life-course smoking prevalence?

OBJECTIVE: An extensive literature uses reconstructed historical smoking rates by birth-cohort to inform anti-smoking policies. This paper examines whether and how these rates change when one adjusts for differential mortality of smokers and non-smokers. METHODS: Using retrospectively reported data from the US (Panel Study of Income Dynamics, 1986, 1999, 2001, 2003, 2005), the UK (British Household Panel Survey, 1999, 2002), and Russia (Russian Longitudinal Monitoring Study, 2000), we generate life-course smoking prevalence rates by age-cohort. With cause-specific death rates from secondary sources and an improved method, we correct for differential mortality, and we test whether adjusted and unadjusted rates statistically differ. With US data (National Health Interview Survey, 1967-2004), we also compare contemporaneously measured smoking prevalence rates with the equivalent rates from retrospective data. RESULTS: We find that differential mortality matters only for men. For Russian men over age 70 and US and UK men over age 80 unadjusted smoking prevalence understates the true prevalence. The results using retrospective and contemporaneous data are similar. CONCLUSIONS: Differential mortality bias affects our understanding of smoking habits of old cohorts and, therefore, of inter-generational patterns of smoking. Unless one focuses on the young, policy recommendations based on unadjusted smoking rates may be misleading.