Gender, education and Russia’s tobacco epidemic: A life-course approach

Highlights

• Life-course smoking histories established for Russia to examine the dynamics of smoking patterns over the past 7 decades.

• Earlier literature may have over-stated the role of economic transition in promoting tobacco consumption in Russia.

• Gender smoking rates have converged over time owing to both increases in female and decreases in male smoking.

• For both genders educational gradient in smoking steepened over time.

• Russian smoking fits the model of the tobacco epidemic and mirrors the patterns observed in Western high-income countries.

Abstract

While a number of studies, based on cross-sectional data for Russia, have documented strong increases in female smoking during the past two decades, the analysis of longer-term trends in smoking prevalence is hampered by the lack of representative data for the Soviet era. In this paper we create life-course smoking histories based on retrospective data from the Russia Longitudinal Monitoring Survey of HSE (RLMS-HSE) and the Global Adult Tobacco Survey (GATS) which allow us to examine the dynamics of smoking patterns over the past 7 decades. We find that smoking rates differ most strongly by gender within all cohorts, but that this differential has decreased over time, driven by increases in female smoking and more recently by decreases in smoking among men. For both genders we observe that the education gradient has become steeper over time, with smoking rates having increased at a higher rate among those with the lowest educational attainment. These findings suggest that the development of smoking in Russia mirrors that described in the model of the tobacco epidemic and observed in Western high-income countries.

Introduction

Russia’s long-term health and demographic problems have been well-documented. There are half a million premature male deaths per annum (Peto et al., 2012) and circulatory disease, the biggest cause of death, kills at about 4 times the rate that it does in the UK, for both men and women (Shkolnikov et al., 2013). While the contribution of alcohol to the excess mortality rates is well-rehearsed, tobacco consumption, which accounts for 150,000 of the excess male deaths annually, receives less attention. However, while male smoking prevalence, which stood at 61 percent in 1995, has declined recently, female smoking has increased from around 9 percent, in 1995, to around 14 percent in 2014. The role of tobacco is therefore a critical one.

In the face of Russia’s catastrophic health profile and the very high levels of engagement in unhealthy behaviours, the Russian government has recently increased its efforts to address these unhealthy behaviours, starting with alcohol policy in the mid-2000s, and subsequently adopting an ambitious anti-smoking law signed by President Putin in 2013. This law ushered in a total ban on advertising, sponsorship, and promotion; a ban on smoking in public buildings, restaurants, workplaces and on public transport; a ban on the sale of tobacco in the ubiquitous Russian street-corner kiosks; and ambitious minimum price and tax increases.

While it is still too early to assess the effectiveness of this legislation, it has certainly transformed the context in which current and future cohorts of potential smokers will live and has pushed Russia dramatically along the tobacco consumption trajectory envisaged in the widely used four-stage model of the “tobacco epidemic” (Lopez et al., 1994). According to this stylised description, based on historic data for a number of developed countries, the prevalence of smoking in a population evolves in a manner similar to an epidemic, spreading from narrow population groups, in to the mainstream, before then declining. A key feature of the model is the 3–4 decade lag with which smoking-related mortality mirrors the pattern of smoking prevalence. Following the initial increase in smoking, the negative health consequences become more visible to the population, the political climate becomes more favourable for tobacco control policies and consequently prevalence rates begin to decline. The original model proposes that smoking rates among women start rising with a lag of 2–3 decades compared to men, due to the stronger prevailing social norms against female smoking. A recent revision however, concludes that, given the complexity of gender-based socio-cultural changes, male and female smoking are best analysed separately (Thun et al., 2012).

The public health literature has extended this model through the ‘diffusion of innovations’ framework. (Rogers, 2003). In this spirit, Pampel et al. (2015), find that in the initial stages of the epidemic, smoking is first adopted by individuals in higher SES groups, which are generally more receptive to innovations, and then spreads to individuals in lower SES groups, leading the smoking gradient to reverse from positive to negative. The same mechanism also posits that the “innovation” of healthy lifestyles is first adopted by individuals of higher SES, in consequence, giving rise to a steepening of the negative smoking-SES gradient.

In this paper, we examine cohort smoking patterns based on data from the Russia Longitudinal Monitoring Survey of HSE (RLMS-HSE) and the Global Adult Tobacco Survey (GATS) and interpret these within the broad descriptive context of the tobacco epidemic model. This is an important task in the Russian case for a number of reasons: (i) the high mortality rates and the associated contribution of smoking-related illness; (ii) the exceptionally high male smoking prevalence and the rising female consumption patterns; (iii) the experience of the Soviet regime and the transition to a market-oriented environment; and (iv) the more recent change in the political climate to one more willing to accommodate tobacco industry regulation.

We argue that the evolution of smoking in Russia is more similar to patterns described in the tobacco epidemic model than has previously been suggested. In doing so, we make three substantive contributions. First, we support the recent finding of Lillard and Dorofeeva (2015) arguing that the earlier literature may have over-stated the role of economic transition in promoting tobacco consumption in Russia. We provide alternative and complementary explanations for that finding. Second, we examine the development of educational gradients in smoking across successive cohorts of smokers. Third, we offer an explanation for potentially important discrepancies in the prevalence and distribution of smoking in Russia that emerge between the RLMS-HSE and the GATS data.

The remainder of the paper proceeds as follows. In Section 2 we survey the most relevant empirical evidence on the historical evolution of smoking, including through describing the data we use in this paper. In Section 3 we outline our main analytical apparatus, in the form of life-course smoking histories. Section 4 then presents and explains our results, which are discussed further in the concluding section.