Neighborhood smoking norms modify the relation between collective efficacy and smoking behavior

Abstract

Background

Although neighborhoods with more collective efficacy have better health in general, recent work suggests that social norms and collective efficacy may in combination influence health behaviors such as smoking.

Methods

Using data from the New York Social Environment Study (conducted in 2005; n = 4000), we examined the separate and combined associations of neighborhood collective efficacy and anti-smoking norms with individual smoking. The outcome was current smoking, assessed using the World Mental Health Comprehensive International Diagnostic Interview (WMH-CIDI) tobacco module. Exposures of interest were neighborhood collective efficacy, measured as the average neighborhood response on a well-established scale, and neighborhood anti-smoking norms, measured as the proportion of residents who believed regular smoking was unacceptable. All analyses adjusted for demographic and socioeconomic characteristics, as well as history of smoking prior to residence in the current neighborhood, individual perception of smoking level in the neighborhood, individual perception of collective efficacy, and individual smoking norms.

Results

In separate generalized estimating equation logistic regression models, neighborhood collective efficacy was not associated with smoking (OR 1.06, 95% CI 0.84–1.34) but permissive neighborhood smoking norms were associated with more smoking (OR 1.34, 95% CI 1.03–1.74), particularly among residents with no prior history of smoking (OR 2.88, 95% CI 1.92–4.30). When considered in combination, where smoking norms were permissive, higher collective efficacy was associated with more smoking; in contrast, where norms were strongly anti-smoking, higher collective efficacy was associated with less smoking.

Conclusions

Features of the neighborhood social environment may need to be considered in combinations to understand their role in shaping health and health behavior.

Introduction

Research in a variety of disciplines including sociology, criminology, and psychology has suggested that cohesiveness and collective power of societies and communities are associated with improved health and wellbeing (Bandura, 2001, Durkheim, 1897, Faris and Dunham, 1939, Shaw and McKay, 1942). In this vein, Bandura introduced the notion of collective agency which he termed “collective efficacy” (Bandura, 2001). This concept combines notions of the cohesiveness of a group (social cohesion), with ideas about their potential efficacy in achieving group goals (informal social control) (Sampson et al., 1997).

In epidemiologic analyses, the presence of collective efficacy in a neighborhood has typically been associated with better health and fewer social ills (Kawachi and Berkman, 2000, Lomas, 1998, Sampson et al., 1997). However, recent discussions suggest that social cohesion, informal social control, and other related constructs may not be unequivocally beneficial (Greiner et al., 2004, Kushner and Sterk, 2005, Portes, 1998). Portes suggests that where social cohesion is high, there is the potential for unhealthy behavioral norms to be enforced on residents (Portes, 1998). Thus, when examining neighborhood cohesion in relation to health behavior, it may be important to consider the norms of the neighborhood in conjunction with the cohesiveness of a neighborhood to understand how the social environment will shape behavior (Durkheim, 1897, Kushner and Sterk, 2005, Portes, 1998). Neighborhoods with high levels of informal social control may enforce local norms on residents, however these norms may or may not be health promoting. Moreover, residents of cohesive neighborhoods may have more contact with one another, providing more opportunities for transmission of norms that, again, may enhance health or may be detrimental.

One health behavior of considerable interest in the context of this discussion is smoking, considered the leading behavioral cause of mortality, contributing to approximately 20% of deaths in the United States by some calculations (Mokdad et al., 2004). In addition to being a strong contributor to morbidity and mortality, smoking is strongly socially shaped and thus may be influenced by both the cohesiveness and the norms of communities. While the prevalence of smoking has been declining overall in the United States, 22% of adults are still current smokers (Trosclair et al., 2005); young people continue to take up smoking and currently approximately 25% of young people are smokers by the time they finish high school (Johnston et al., 2006). Broad national and statewide norm-changing media campaigns, smoking restriction legislation, and tobacco taxation that have attempted to change the social and structural environment of smoking are credited with contributing to the smoking declines to date; however, these declines have not been experienced equally in all populations, and there remains substantial variation in smoking geographically (Gilpin et al., 2004, Jiles et al., 2005, Nelson et al., 2001, Pierce et al., 1998). The local variation in smoking raises the question of what neighborhood social and structural characteristics might shape smoking behavior.

There is substantial research suggesting that neighborhood socioeconomic indicators are associated with smoking, however there is little research on other social and structural aspects of neighborhoods that may be related to smoking (Chuang et al., 2005a, Cubbin et al., 2006, Datta et al., 2006, Davey Smith et al., 1998, Diez Roux et al., 1997, Duncan et al., 1999, Ecob and Macintyre, 2000, Kleinschmidt et al., 1995, Monden et al., 2006, Ohlander et al., 2006, Reijneveld, 1998, Reijneveld, 2002, Ross, 2000, Sundquist et al., 1999, Tseng et al., 2001, van Lenthe and Mackenback, 2006). There have been two studies examining neighborhood cohesion and control in association with smoking, and both found that more cohesive neighborhoods had lower prevalences of smoking (Miles, 2006, Patterson et al., 2004). There are no studies of neighborhood smoking norms and smoking among adults. Most of the research on substance use norms has been conducted in adolescents, and the norms have not typically been conceptualized as neighborhood level properties. The existing studies among adolescents show the importance of adult and peer norms for predicting smoking (Chuang et al., 2005b, Eisenberg and Forster, 2003, Ellickson et al., 2003, Ennett et al., 1997, Frohlich et al., 2002), suggesting these may be important social properties to consider in the context of adult smoking.

The potential importance of neighborhood collective efficacy and substance use norms in shaping smoking behavior is clear. However, the only extant research on the convergence of collective efficacy and smoking norms comes from one qualitative study conducted in Scotland (Stead et al., 2001). In the neighborhood studied, smoking was used to cope with a variety of stressors including unemployment and unsafe environments. In addition, there were strong pro-smoking norms in the neighborhood and a strong sense of local identification and cohesiveness. The cohesiveness and norms seemed to combine, such that “…these positive aspects of life [such as cohesiveness] may ironically be as bound up with and reinforcing of smoking as the more negative aspects of life [such as stressors]” (Stead et al., 2001).

In this analysis, we examined the relations of neighborhood collective efficacy and neighborhood smoking norms with smoking behavior, both separately and in combination. Building on the extant literature, we hypothesized that the association between collective efficacy and smoking would to be modified by the norms of the community, and specifically that the association would be reversed; cohesive neighborhoods with permissive smoking norms would have the highest smoking, and cohesive neighborhoods with strong anti-smoking norms would have the lowest smoking. Moreover, in this analysis we applied methods that address the problems of stratification and social selection which are challenges to interpreting neighborhood research (Oakes, 2004). In this analysis, we examine large neighborhood areas in New York City (NYC). While these areas are larger than neighborhoods examined in many studies (Sampson et al., 1997), it is interesting to examine whether these processes operate at a larger scale.