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2007 to 2008 (Dube et al., 2009). More generally, cigarette use persists at frustratingly high levels in all high-income nations. Using figures circa 2000, the Tobacco Atlas (Mackay, Eriksen, and Shafey, 2006) reports that about 35 percent of men and 22 percent of women in developed nations smoke; Cutler and Glaeser (2006) report that in 17 European nations an average of 30 percent smoke.

The persistence of smoking relates closely to socioeconomic status (SES) differences in health behaviors. The decline in smoking has proceeded fastest among high-SES groups, leaving disadvantaged groups as the primary users of cigarettes (Pampel, 2005). Of the components of SES, education proves a stronger predictor of smoking than occupation or income, although higher levels of all three are associated with lower smoking (Barbeau, Krieger, and Soobader, 2004; Huisman, Kunst, and Mackenbach, 2005a). For example, analysis of the 2006 U.S. National Health Interview Survey shows that odds ratios of smoking equal 3.7 for high school dropouts relative to college graduates, 2.2 for laborers and farmers relative to professionals and managers, and 2.6 for the lowest income quartile relative to the highest income quartile. Rock et al. (2007) report that 43.5 percent of those with 9 to 11 years of education smoke, compared with 10.0 percent of those with an undergraduate degree and 7.3 percent of those with a graduate degree. Even among the most educated, the low rates still translate into millions of smokers. Among the less educated, the problem is considerably worse and has led to government efforts in the United States to focus on eliminating SES disparities in smoking (Fagan et al., 2004).1

Second, high-income nations show considerable diversity around the average. Despite similarly high levels of economic development compared with the rest of the world and educated populations largely familiar with the harm of tobacco, the high-income nations of Western Europe plus Australia, Canada, Japan, New Zealand, and the United States differ in the prevalence and intensity of use. For example, according to figures from Cutler and Glaeser (2006) for the European Union, smoking rates range from 19 and 21 percent in Sweden and Portugal, respectively, to 34 percent in Spain, 35 percent in Germany, and 38 percent in Greece. The Tobacco Atlas (Mackay et al., 2006) reports smoking percentages of 17 percent in Sweden, 20 percent in Portugal, 32 percent in Germany, 32 percent in Spain, and 38 percent in Greece. That is, smoking is at least twice as common in some

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The stronger influence of education stems in part from its stability over the life course; it changes less than occupation and income from adolescence and young adulthood, when most people start to smoke. Even at that, the effects of education are complex. Youth often make decisions to smoke or not smoke before they complete their education, suggesting that the SES background of parents affects the smoking behavior of their children or that latent traits of youth affect both healthy behavior and educational attainment. In addition, learning that occurs during higher levels of education can prevent later starting and foster quitting.



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