摘要：Objectives. We examined the separate and combined relations of neighborhood-level social norms and collective efficacy with individuals’ cigarette smoking cessation. Methods. We modeled the hazard of quitting over a 5-year period among 863 smokers who participated in the 2005 New York Social Environment Study. Results. In adjusted Cox proportional hazard models, prohibitive neighborhood smoking norms were significantly associated with higher rates of smoking cessation (second quartile hazard ratio [HR] = 1.17; 95% confidence interval [CI] = 0.59, 2.32; third quartile HR = 2.37; 95% CI = 1.17, 4.78; fourth quartile HR = 1.80; 95% CI = 0.85, 3.81). We did not find a significant association between neighborhood collective efficacy and cessation or significant evidence of a joint relation of collective efficacy and smoking norms with cessation. Conclusions. Neighborhood social norms may be more relevant than is collective efficacy to smoking cessation. The normative environment may shape health behavior and should be considered as part of public health intervention efforts. Cigarette smoking is one of the most important causes of preventable morbidity and premature mortality worldwide. Restrictions on permissible locations for smoking have increased in scope and number over the past 2 decades in the United States, and rates of smoking have declined. Nonetheless, an estimated 45.3 million (19.3%) adults in the United States still smoke, and each year, smoking-related diseases claim 443 000 American lives. 1a-b Given the continued high prevalence of smoking and the reduction in risk of disease and premature mortality provided by quitting, 2,3 there is a need to identify factors that support smoking cessation that interventions could target. Past studies have documented the importance of social networks in the cessation of smoking. 4,5 Further study of social determinants of smoking cessation has the potential to inform interventions that promote health by altering the structural context (e.g., changing norms and taxation practices) to complement more traditional individual behavior change approaches. 6 Substantial variations in the rates of disease by region, state, county, and neighborhood have long been noted. 7–9 There is growing evidence that variations in rates of disease are determined not only by different distributions of individuals between places but also by the social and physical environments in which people live. 10,11 Neighborhoods have long been studied as geographic units wherein residents have distinct social ties, common exposures, and access to resources. Indeed, smoking patterns vary by geographical location, suggesting that aspects of the social and physical environment influence individual smoking behavior. 12 Existing research suggests that characteristics of neighborhoods shape the risk of smoking. 13–15 There is evidence that smoking is associated with neighborhood deprivation and low socioeconomic status. 14–19 The role of neighborhood factors in smoking cessation has been less frequently studied. The only study to examine the relations between the neighborhood environment and smoking cessation found that there was more quitting in areas with higher socioeconomic status. 14 Examining other social environment characteristics in relation to smoking cessation may increase our understanding of how the social environment shapes smoking cessation and suggest avenues for structural intervention. Social norms, broadly defined as rules that dictate acceptable behavior within a group, are one aspect of the neighborhood social environment that merits study in relation to smoking cessation. Research suggests that social networks may influence smoking cessation through group social smoking norms. 4,5 Similarly, the neighborhood social environment may influence individual smoking cessation by giving rise to social norms that define the boundaries of permissible or desirable behaviors. Situational norms and attitudes have been linked to alcohol consumption, 20 dietary intake, 18 and smoking prevalence. 16,18,21 Community social norms are considered a contextual influence in the smoking literature 16,18,22–25 ; however, studies examining the role of norms typically use individual perceptions of norms rather than group-level measures of norms. Of the few studies that have examined social norms and smoking cessation, 1 found that individual perception of social norms surrounding smoking contributed to smoking behavior, including cessation, among adolescents. 24 Another study found greater quit ratios in immigrant communities in the United States, pointing to a possible role of social norms influencing behavior. 26 The limited existing research suggests that neighborhood social norms are worth examining as a potential factor that shapes smoking cessation. The closeness of social relationships in a neighborhood is another aspect of the neighborhood social environment that merits study in relation to smoking cessation. Collective efficacy is a neighborhood construct that measures the cohesiveness of a group (social cohesion) and the group's ability to act to achieve goals (informal social control). 27 Groups with higher efficacy have agency to produce desired effects and limit undesired ones through their collective action. 28 Analyses have shown that higher levels of collective efficacy in a neighborhood protect against negative health outcomes. 29 Higher levels of collective efficacy have been associated with lower levels of violent crime and homicide rates, 27 obesity in youth, 30 and heart disease mortality. 31 There is limited research on smoking and collective efficacy. Although studies have shown that smoking risk is higher in neighborhoods with lower levels of collective efficacy, these studies did not investigate smoking cessation. 32–34 Related constructs of individual perception of social capital and social participation have been associated with smoking cessation. 35–37 Thus, the literature supports the possibility that neighborhood smoking norms and collective efficacy are important in shaping smoking cessation, but the associations have not yet been examined. Existing research also suggests a potential convergence of these neighborhood characteristics in shaping smoking cessation. The impact of social norms on smoking cessation may depend on the closeness and influence of social relationships within a neighborhood environment. This notion is supported by a qualitative study in a community in Glasgow, Scotland, that found that high cohesion and strong prosmoking norms combined not only to foster smoking but also to discourage or undermine cessation. 38 This convergence was also supported by a quantitative multilevel study that found that in neighborhoods where norms were strongly antismoking, higher collective efficacy protected against smoking and the individual odds of smoking were lower. 16 Informed by the existing literature, we examined relations between the social environment of a neighborhood, as characterized by smoking norms and collective efficacy, and individual smoking cessation. We tested 3 specific hypotheses: (1) neighborhood norms that are less accepting of smoking are positively associated with the incidence of individual smoking cessation, (2) higher levels of neighborhood collective efficacy are positively associated with the incidence of smoking cessation, and (3) neighborhood smoking norms and collective efficacy interact such that smoking cessation is highest where levels of collective efficacy are high and norms are less accepting of smoking.
