Losing jobs and lighting up: Employment experiences and smoking in the Great Recession

Involvement of common risk factors in the associations between lifetime unemployment exposure, major health outcomes and mortality: a retrospective and prospective study in a large population-based French cohort

OBJECTIVES

Uncertainty exists as to what extent common risk factors are involved in the associations of unemployment with major health outcomes and mortality.

DESIGN

A retrospective and prospective observational study.

SETTING

A large population-based French cohort (CONSTANCES).

PARTICIPANTS

99 430 adults at baseline who have been exposed to unemployment during their lifetime and 54 679 of them who were followed for 7 years after baseline.

PRIMARY OUTCOME MEASURES

Testing the mediating roles of several risk factors at baseline in the associations of lifetime unemployment exposure with cardiovascular disease, cancer and mortality rates during a 7-year follow-up. Direct and indirect effects were calculated for each risk factor and all together using logistic regression models adjusted for major confounders including sex, age, parental histories of cardiovascular disease and cancer, social position and working conditions.

RESULTS

Estimates (95% CIs) of the direct and indirect effects for smoking are 0.0083 (0.0044 to 0.0122), p<0.0001 and 0.0010 (0.0007 to 0.0014), p<0.0001 on cardiovascular disease rate; 0.0059 (0.0028 to 0.0089), p=0.0002 and 0.0007 (0.0004 to 0.0010), p<0.0001 on cancer rate; 0.0105 (0.0058 to 0.0151), p<0.0001 and 0.0010 (0.0005 to 0.0014), p<0.0001 on all-cause mortality. The figures for alcohol consumption are, respectively, 0.0076 (0.0034 to 0.0118), p=0.0004 and 0.0004 (0.0002 to 0.0005), p=0.0006; 0.0067 (0.0035 to 0.0100), p<0.0001 and 0.0004 (0.0002 to 0.0005), p<0.0001; 0.0114 (0.0064 to 0.0164), p<0.0001 and 0.0004 (0.0001 to 0.0006), p=0.0009. For depressive symptoms, 0.0084 (0.0040to 0.0128), p=0.0002 and 0.0007 (0.0002 to 0.0011), p=0.005; 0.0053 (0.0017 to 0.0089), p=0.004 and 0.0001 (-0.0002 to 0.0005), p=0.51; 0.0088 (0.0031 to 0.0144), p=0.002 and 0.0010 (0.0004 to 0.0015), p=0.0005. For leisure-time physical inactivity, 0.0083 (0.0044 to 0.0122), p<0.0001 and 0.0003 (0.0001 to 0.0005), p=0.0006; 0.0057 (0.0026 to 0.0088), p=0.0004 and 0.0002 (0.0001 to 0.0003), p=0.002; 0.0105 (0.0058 to 0.0152), p<0.0001 and 0.0004 (0.0002 to 0.0007), p<0.0001. For blood triglycerides, 0.0080 (0.0042 to 0.0119), p<0.0001 and 0.0005 (0.0004 to 0.0007), p<0.0001; 0.0057 (0.0026 to 0.0087), p=0.0003 and 0.0001 (-0.0001 to 0.0002), p=0.32; 0.0103 (0.0057 to 0.0149), p<0.0001 and 0.0002 (0.0000 to 0.0004), p=0.06. The figures for all risk factors when tested together were 0.0075 (0.0022 to 0.0128), p=0.005 and 0.0020 (0.0011 to 0.0027), p<0.0001; 0.0052 (0.0011 to 0.0093), p=0.01 and 0.015 (0.0009 to 0.0020), p<0.0001; 0.0102 (0.0035 to 0.0169), p=0.003 and 0.0022 (0.0011 to 0.0031), p<0.0001.

CONCLUSIONS

These analyses show that common risk factors such as smoking, alcohol consumption, depressive symptoms, leisure-time physical inactivity and blood triglycerides mediate up to 10% of the associations of lifetime unemployment exposure with cardiovascular disease, cancer and mortality rates when tested separately and approximately 20% when tested all together. This highlights the existence of other major mediating pathways that have yet to be identified.

Breaking Bonds, Changing Habits: Understanding Health Behaviors during and after Marital Dissolution

Marital dissolution is a stressful transition that can lead to unhealthy coping strategies, including smoking and drinking. Using fixed effect linear probability models to assess health behavior changes, we analyzed 6,607 women and 6,689 men in the Household, Income, and Labour Dynamics in Australia data set who were either continuously married or experienced marital separation between 2002 and 2020. We observed 1,376 separations (744 women, 632 men). We found that drinking and smoking increases leading to and in the year of separation, with variability by gender, education, and parenthood status. From Cox proportional hazards models, we showed that among individuals who smoked (N = 337) or drank (N = 756) in the year of separation, cessation was most likely for the highly educated and/or women. Unhealthy coping mechanisms throughout marital dissolution suggests a need for targeted support to those separating, especially for men and those with children and lower education.

Association of cigarette smoking with changes in macroeconomic conditions

This study uses data from the 1987-2022 Behavioral Risk Factor Surveillance System and state-level employment rates from the US Bureau of Labor Statistics to estimate the association between macroeconomic conditions and cigarette smoking. Our finding suggests a positive association, which constantly declined with time after the 2001 recession. We find that a one percentage point increase in the employment rate is associated with a 1.4% higher likelihood of smoking cigarettes in the overall sample but declined to 0.4% among cohorts surveyed from 2011 to 2022. We also find strong positive and heterogeneous associations among sociodemographic groups, except among Blacks and persons aged 65 years and older, among whom there is no association; however, the positive associations consistently decreased among these sociodemographic groups. Consequently, the strong positive association disappeared in several sociodemographic groups in cohorts surveyed over the last decade.

Identifying the impact of the business cycle on drug-related harms in European countries

BACKGROUND

The evidence resulting from the analysis of the association between economic fluctuations and their impact on the substance use is mixed and inconclusive. Effects can be pro-cyclical (drug-related harms are predicted to rise when economic conditions improve), counter-cyclical (drug-related harms are predicted to rise in bad economic times) or unrelated to business cycle conditions as different transmission mechanisms could operate simultaneously.

METHODS

The main aim of this study is to assess, from a macroeconomic perspective, the impact of economic cycles on illegal drug-related harms in European countries over the 2000-2020 period. To this end, the regime-dependent relationship between drug-related harm, proxied by unemployment, and the business cycle, proxied by overdose deaths will be identified. Applying a time dynamic linear analysis, within the framework of threshold panel data models, structural-breaks will also be tested.

RESULTS

The relationship between economic cycles (proxied by unemployment) and drug-related harms (proxied by overdose deaths) is negative, and therefore found to be pro-cyclical. One percentage point in the country unemployment rate is predicted to reduce the overdose death rate by a statistically significant percentage of 2.42. A counter-cyclical component was identified during the 2008 economic recession. The threshold model captures two effects: when unemployment rates are lower than the estimated thresholds, ranging from 3.92% to 4.12%, drug-related harms and unemployment have a pro-cyclical relationship. However, when unemployment rates are higher than this threshold, this relationship becomes counter-cyclical.

CONCLUSIONS

The relationship between economic cycles and drug-related harms is pro-cyclical. However, in situations of economic downturns, a counter-cyclical effect is detected, as identified during the 2008 economic recession.

Stepping into adulthood during a recession: Did job losses during the Great Recession impact health of young adults?

This is the first study to comprehensively examine the impact of job losses during the Great Recession on mental health, physical health, health behavior, and risky health behavior of young adults (ages 18-27). We employ U.S. longitudinal data with individual fixed effects to control for time-invariant factors that may bias the results. We find that job losses during the recession of young adults living by themselves led to increased onset of doctor-diagnosed mental health problems and worries related to jobs. Poorer individuals suffered more from increased worries, obesity, and binge drinking. In contrast, for those living with their parents, job loss of young adults did not negatively affect their own health. Instead, fathers' job losses led to worse mental health, physical health, and health behavior for young adults. Overall, the results suggest that when living on their own, young adults were responsible for their households' livelihood, and consequently, own job losses led to stress and negative health outcomes. However, when living with parents, they were financially reliant on their parents. Therefore, own job losses did not affect health, but job losses of fathers, the primary income earners for most households, worsened the health of young adults.

Inequalities in Smoking and Quitting-Related Outcomes Among Adults With and Without Children in the Household 2013-2019: A Population Survey in England

INTRODUCTION

Smoking among those who live with children is an important influence on smoking initiation among children. This study assessed socioeconomic inequalities in smoking and quitting-related outcomes among all adults with and without children in the household.

AIMS AND METHODS

Monthly repeat cross-sectional household survey of adults (16+) from 2013-2019 in England (N = 138 583). We assessed the association between cigarette smoking and quitting-related outcomes and having children in the household, and whether these relationships were moderated by occupational social grade (categories AB-E from most to least advantaged). Trends in smoking prevalence among adults with and without children in the household were explored.

RESULTS

In adjusted analysis, the association of having children in the household with smoking prevalence depended on social grade: smoking prevalence was between 0.71 (95% confidence interval 0.66-0.77) and 0.93 (0.88-0.98) times lower among social grades AB-D with children in the household relative to those without. Conversely, it was 1.11 (1.05-1.16) times higher among social grade E. Yearly prevalence declined similarly among those with and without children (both prevalence ratio: 0.98, 95% confidence interval 0.97-0.99). Motivation to stop smoking was higher among those with children than those without, but lower among disadvantaged than more advantaged groups. Social grades D-E had greater heavy smoking, but higher prevalence of past-month quit attempts.

CONCLUSIONS

Among the most disadvantaged social grade in England, smoking prevalence was higher in those with children in the household than without. To attenuate future smoking-related inequalities, there is an urgent need to target support and address barriers to quitting and promote longer-term quit success.

IMPLICATIONS

In the most disadvantaged occupational social grade, having children in the household was associated with higher smoking prevalence compared with not having children. This contrasts with all other social grades in which there was lower comparative smoking prevalence among those with than without children in the household. Without attention this disparity could exacerbate existing and future health inequalities related to smoking.

Long-term effects of job loss on male health: BMI and health behaviors

Employment is one of the most critical determinants of health and health behaviors for adults. This study focuses on Ukraine and measures how an involuntary job loss - defined as job loss due to business closures, reorganizations, bankruptcies, or privatization - affects BMI, being overweight or obese, smoking, alcohol consumption, and physical activity. There are three reasons to study Ukraine in the aftermath of an enormous economic transition that resulted in employment contraction as high as 40 % compared to 1990. First, nearly all published studies on the relationship between job loss and health and health behaviors have been on developed countries, meaning that our study fills the gap in the literature on transition economies. Second, the job losses that we study are plausibly exogenous and affected a significant share of the population. Third, the longitudinal survey follows individuals for up to 10 years starting from 2003, allowing us to capture the long-term effects of past job loss on outcomes at a specific point in time and their trajectories across the life cycle. Applying growth-curve models, we show that past involuntary job loss significantly alters the age trajectories of all considered outcomes at both extensive and intensive margins.

New evidence on the impact of the Great Recession on health-compromising behaviours

Using data from the English Longitudinal Study of Ageing over the period 2004-2017, this paper explores the effects of the Great Recession and its aftermath upon health-compromising behaviours in adults aged 50 and over. We introduce new techniques into this area of research, namely dynamic random-effects logit estimators which control for initial conditions and correlated individual effects. We observe a lack of crisis effect upon the probabilities of smoking and being physically inactive, as well as of transitioning in and out of these behaviours. In line with other recent literature, this suggests that the relationship between economic recessions and smoking and physical inactivity may have broken down. Alternatively, the over 50s may have been protected from the crisis and subsequent austerity measures. Nonetheless, both the crisis and post-crisis period were associated with a lower probability of drinking frequently.

The role of income and psychological distress in the relationship between work loss and smoking cessation: Findings from three International Tobacco Control (ITC) Europe countries

INTRODUCTION

The relationship between work loss and smoking has not been studied extensively, and underlying factors are often not examined. The aim of this study was to test two hypotheses. First, work loss is associated with greater intention to quit and more likelihood of smoking cessation, and this relationship is moderated by a decrease in income. Second, work loss is associated with lower quit intention and lower rates of smoking cessation, and this relationship is moderated by an increase in psychological distress.

METHODS

We used pooled data from three countries participating in the ITC Project: France, Germany and the Netherlands (n=2712). We measured unemployment, income and psychological distress at two consecutive survey waves, and calculated changes between survey waves. We first conducted multiple logistic regression analyses to examine the association between work loss and smoking cessation behavior. Next, we added income decrease and psychological distress increase to the models. Finally, we added interaction terms of work loss by income decrease and work loss by distress increase to the model.

RESULTS

Work loss was not associated with quit intention, quit attempts, and quit success. When income decrease and psychological distress increase were added to the model, we found a positive association between distress increase and quit attempts. The interactions, however, were not statistically significant.

CONCLUSIONS

Our results indicate that smokers who become unemployed and face a decrease in income are not less likely to quit smoking than smokers who are employed.

Association between unemployment and the co-occurrence and clustering of common risky health behaviors: Findings from the Constances cohort

Background

Unemployment is associated with a high prevalence of risky health behaviors. Mortality increases with the number of co-occurring risky behaviors but whether these behaviors co-occur with a greater than expected frequency (clustering) among unemployed people is not known.

Methods

Differences according to unemployment status in co-occurrence and clustering of smoking, alcohol abuse, low leisure-time physical activity and unhealthy diet (marked by low fruit and vegetable intake) were assessed in 65,630 salaried workers, aged 18 to 65, who were participants in Constances, a French population-based cohort. Among them, 4573 (7.0%) were unemployed without (n = 3160, 4.8%) or with (n = 1413, 2.1%) past experience of unemployment.

Results

Compared to the employed, unemployed participants without or with past experience of unemployment were similarly overexposed to each risky behavior (sex and age adjusted odds-ratios ranging from 1.38 to 2.19) except for low physical activity, resulting in higher rates of co-occurrence of two, three and four behaviors (relative risk ratios, RRR 1.20 to 3.74). Association between behavior co-occurrence and unemployment did not vary across gender, partnership status or income category. Risky behavior clustering, i.e., higher than expected co-occurrence rates based on the prevalence of each behavior, was similar across unemployment status. The same observations can be made in employed participants with past experience of unemployment, although overexposure to risky behaviors (ORs 1.15 to 1.38) and increased rates of co-occurrence (ORs 1.19 to 1.58) were not as pronounced as in the unemployed.

Conclusions

Co-occurrence of risky behaviors in currently and/or formerly unemployed workers is not worsened by behavior clustering. Engagement in each of these behaviors should be considered an engagement in distinct social practices, with consequences for preventive policies.

The effect of unemployment on the smoking behavior of couples

Although unemployment likely entails various externalities, research examining its spillover effects on spouses is scarce. This is the first paper to estimate effects of unemployment on the smoking behavior of both spouses. Using German Socio-Economic Panel data, we combine matching and difference-in-differences estimation, employing the post-double-selection method for control variable selection via Lasso regressions. One spouse's unemployment increases both spouses' smoking probability and intensity. Smoking relapses and decreased smoking cessation drive the effects. Effects are stronger if the partner already smokes and if the male partner becomes unemployed. Of several mechanisms discussed, we identify smoking to cope with stress as relevant.

The association between gender roles and smoking initiation among women and adolescent girls

Smoking cigarettes is a leading global cause of preventable death and disease. Men historically smoke more than women, but the prevalence of smoking among women in low and middle-income countries is increasing at an alarming rate. Understanding the factors that influence smoking initiation among women and girls is needed to address the growing epidemic of women smokers and the looming impact on women's health worldwide. We assume that smoking initiation is embedded in socio-culturally influenced gendered context and use a social cognitive model with a gendered lens as a framework for organizing and synthesizing the research. Guided by this framework, we identified gaps in the literature and make recommendations for future research in this review paper. The results suggest that psychological and environmental determinants are rooted in fluctuating cultural influences and values, but few research studies provide a gendered analysis or systematically examine these factors in the context of gender and culture. Sex/gender is a significant construct through which women and girls experience the psychological, environmental, and other influences on smoking initiation. Much more research is needed to understand the psychological and environmental influences as well as the intersection of gender roles and other social categories on female smoking initiation.

Quality and quantity: The association of state-level educational policies with later life cardiovascular disease

Education is a powerful predictor of cardiovascular morbidity and mortality. While the majority of the literature has focused on years of educational attainment or degree attainment, fewer studies examine the role of educational quality in the prevention of cardiovascular disease (CVD). We tested the hypothesis that average state-level educational quality was associated with CVD, linking state-level data on educational quality with individual demographic and health data from multiple waves of the National Health and Nutrition Examination Survey (N = 34,770). We examined thirteen CVD-related outcomes-including blood pressure, cholesterol, and heart attack-to understand the multiple pathways through which educational quality may influence CVD. The primary predictor was a composite index of educational quality, combining state-level measures of student-teacher ratios, per-pupil expenditures, and school term length. We fit multivariable models, regressing each outcome on the educational quality composite index and adjusting for individual- and state-level covariates. We also assessed whether the association between state educational quality and CVD differed for less educated individuals. Overall, higher educational quality was associated with less smoking (OR = 0.86, 95%CI: 0.77, 0.97), but there was no statistically significant association for the other 12 outcomes. Interaction tests indicated that less educated individuals benefited less from higher educational quality relative to those with more education for several outcomes. Our study suggests that state-level educational quality is not strongly associated with CVD, and that this null association overall may mask heterogeneous benefits that accrue disproportionately to those with higher levels of education.

Current smoking and quit-attempts among US adults following Medicaid expansion

The objective of this study was to estimate the influence of the Affordable Care Act (ACA) Medicaid Expansion on current smoking and quit attempts in expanded and non-expanded states. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 through 2015 to evaluate changes in current smoking and quit attempts using multivariable logistic regression and generalized estimating equations (GEE), adjusting for socioeconomic factors. Time periods evaluated were: 2003–2009 (pre-expansion) and 2011–2015 (post-expansion), and in supplemental analysis, also 2011–2017. Overall, smoking prevalence among adults in expanded and non-expanded states were 16% and 17% (p < 0.001), respectively, and quit attempt prevalence for expanded and non-expanded states were 56% and 57% (p = 0.05), respectively. In adjusted models comparing post- versus pre- expansion periods, current smoking declined by 6% in both expanded (RR: 0.94, 95% CI: 0.93–0.94) and non-expanded (RR: 0.94, 95% CI: 0.94–0.95) states. Quit attempts increased by 4% (RR: 1.04, 95% CI: 1.04–1.05) in expanded states, and by 3% (RR: 1.03, 95% CI: 1.02–1.03) in non-expanded states. States that imposed barriers to utilization of smoking cessation services e.g. prior authorization, saw only a 3% increase in quit attempts regardless of expansion status, while expanded states that did not impose barriers experienced a 6% (RR: 1.06, 95% CI: 1.05–1.06) increase in quit attempts. Reducing administrative barriers to smoking cessation programs may enhance further declines in smoking rates among US adults.

Effects of the 2008 global financial crisis on population health

We compare the transmission channels through which the 2008 global financial crisis affected health. We find that postponing or skipping visits to the doctor after falling ill and stopping buying regular medication had the strongest negative effects on health, followed by a reduced consumption of staple foods, utilities being cut, being forced to move, and having to sell assets. In comparison, experiencing cuts in TV, phone, and internet services, as well as delaying payments for utilities had relatively weaker negative impacts. In contrast, having a household head or household member lose a job also had negative effects on health status, although this effect was relatively lower. Finally, a reduced flow of remittances had the weakest negative effect.

The buffering role of the family in the relationship between job loss and self-perceived health: Longitudinal results from Europe, 2004-2011

Unemployment has numerous negative consequences for health, but the family and the welfare state can mitigate these consequences. How the family supports its members and whether and to what extent this interacts with the broader context is still an open question. Our evidence show that job loss is causally linked to significant declines in health for men, but not for women. Yet, the increased risk of poor health is lower for coupled men, especially if the partner is employed. This suggests that both emotional and economic support play a role. Moreover, the family's mitigating role widely varies across different welfare regimes in Europe and it is particularly strong in Southern and Eastern regimes, characterized by "rudimentary" welfare systems and a more traditional family model.

Unemployment, drugs and attitudes among European youth

This paper studies changes in the patterns of drug consumption and attitudes towards drugs in relation to sky-high (youth) unemployment rates brought about by the Great Recession. Our analysis is based on data for 28 European countries that refer to young people. We find that the consumption of cannabis and 'new substances' is positively related to increasing unemployment rates. An increase of 1% in the regional unemployment rate is associated with an increase of 0.7 percentage points in the ratio of young people who state that they have consumed cannabis at some point in time. Our findings also indicate that higher unemployment may be associated with more young people perceiving that access to drugs has become more difficult, particularly access to ecstasy, cocaine and heroin. According to young Europeans, when the economy worsens, anti-drug policies should focus on the reduction of poverty and unemployment, and not on implementing tougher measures against users.

Business cycle impacts on substance use of adolescents: A multi-country analysis

Populations respond to changes in the economic climate in a variety of ways. The recent 'Great Recession' has brought attention to the vulnerability of many economies around the world to changes in non-domestic macroeconomic fluctuations. However, empirical evidence on the responses of adolescents' substance consumption behaviour when the economy deteriorates is very scarce. Thus, the focus of this paper is to analyse the substance consumption patterns displayed by adolescents in response to changes in macroeconomic conditions in a large number of countries. Our results show that beer and wine consumption vary counter-cyclically (a 1pp increase in the unemployment rate increases the probability of drinking beer (wine) by 3% (5.5%)) while adolescent smoking prevalence varies pro-cyclically (a 1pp increase in the unemployment rate decreases the probability of being a current smoker by 3.8%). More importantly, we find that the probability of ever being drunk increases by 1.3% for a 1pp increase in the unemployment rate. Further to this, substantial heterogeneous effects from the aggregate-level results were found when analysing a variety of demographic and geographic dimensions. In light of the existing empirical evidence which outlines that early substance initiators demonstrate worse neurological deficits and suffer stronger labour market penalties (compared to later initiators or abstainers) these findings can aid policy makers in reducing these lasting adverse outcomes.

Trends in smoking and obesity among US adults before, during, and after the great recession and Affordable Care Act roll-out

This study examined trends in smoking and overweight/obesity rates among United States (US) adults ages 40years and older by race and socio-economic status (SES) across three study periods; pre-recession (2003-2005), recession (2007-2009), and post-recession/Affordable Care Act (2010-2012). Data was obtained from the Behavioral Risk Factor Surveillance System (BRFSS), and multivariable regression analysis was used to examine changes in overweight/obesity, smoking, physical activity and smoking cessation rates over the study periods. There were 2,805,957 adults included in the analysis; 65.5% of the study population was overweight/obese, and 33.3% were current smokers. Smoking prevalence increased marginally among those with lower SES (income<$10,000) from pre-recession (52.5%) to post-recession (52.9%), but declined in other socio-demographic groups. The odds of overweight/obesity increased in the post-recession (OR: 1.22, 95% CI: 1.21-1.23) and recession (OR: 1.11, 95% CI: 1.11-1.12) periods compared with pre-recession, but odds of smoking overall decreased in the post-recession (OR: 0.93, 95% CI: 0.92-0.94) and recession (OR: 0.95, 95% CI: 0.94-0.97) periods. Overweight/obesity increased over the study periods, regardless of race, SES or healthcare access, while smoking rates showed significant declines post-recession compared with pre-recession, except in low SES groups. These findings suggest that strategies focused on reducing overweight/obesity and increasing access to smoking cessation services, especially among low-income adults, are needed. Prospective studies are needed to better evaluate the influence of the economic recession and Affordable Care Act on behavioral risk factors.

Effects of the great recession on drugs consumption in Spain

This paper presents evidence on how the consumption of legal and illegal drugs has changed in response to the Great Recession in Spain. We use a large scale survey from 2005 to 2011 to analyze the association between changes in local economic conditions and drug consumption among individuals aged 15-64. Although Spain was one of the countries hardest hit by the economic downturn, the crisis was unevenly felt across the country. Therefore, we exploit this difference in unemployment rates across provinces to identify the effects of business cycle variations on the consumption of legal and illegal drugs. To the best of our knowledge, this is the first study to find a relation between the deterioration of local economic conditions and a strong increase in the consumption of marihuana and cocaine. We also report a decrease in alcohol consumption but a significant escalation in abusive smoking behavior (smoking every day). We believe that these findings are important not only for the potential negative implications at the individual level but also for the costs to society as a whole.