Heterogeneity in the determinants of health and illness: the example of socioeconomic status and smoking

Systematic variations in health and illness among social groups have persis ted and, in some cases increased, in many countries in spite of improvement s in the availability of, and access to, health care services. Health polic y makers have responded by showing increasing interest in non-clinical dete rminants of health as a way of explaining the observed systematic variation s in health and illness. Yet health care and non-health care "factors" are often seen as competing for society's scarce resources in the production of health. The purpose of this paper is to augment this traditional approach to understanding the determinants of health in populations by exploring het erogeneity in the smoking-health relationship between social groups. Logist ic regression analyses were performed using data from the 1992-93 Sante Que bec survey, a weighted random sample of the non-institutionalized populatio n of the province of Qui bcc, Canada (N = 23,564). The findings suggest tha t the likelihood of reporting health as poor or fair was greater for smoker s than non-smokers. However, the difference between smokers and non-smokers was significantly greater among groups of the population with low incomes and without employment, but significantly less among sub-groups with lower levels of education. These findings suggest that the identification, evalua tion and implementation of health care programmes need to pay greater atten tion to the interface between social, behavioural and clinical determinants of health. (C) 2000 Elsevier Science Ltd. All rights reserved.