摘要：In the United States in 1997, the smoking prevalence among blue-collar workers was nearly double that among white-collar workers, underscoring the need for new approaches to reduce social disparities in tobacco use. These inequalities reflect larger structural forces that shape the social context of workers’ lives. Drawing from a range of social and behavioral theories and lessons from social epidemiology, we articulate a social-contextual model for understanding ways in which socioeconomic position, particularly occupation, influences smoking patterns. We present applications of this model to worksite-based smoking cessation interventions among blue-collar workers and provide empirical support for this model. We also propose avenues for future research guided by this model. Persistent and growing disparities in smoking prevalence by occupation underscore the need for new approaches to tobacco control. In the United States in 1997, the smoking prevalence among male blue-collar workers was nearly twice that of men in white-collar occupations (37% vs 21%), and similar disparities were observed among women (33% for women in blue-collar vs 20% for those in white-collar occupations). 1 In addition, blue-collar workers’ rates of smoking are declining more slowly than those of other workers. 2 A recent analysis of data from the 2000 National Health Interview Survey found that smoking prevalence was highest among persons with working-class jobs, low education, and low income and that each of these indicators of socioeconomic position was independently and positively associated with smoking prevalence. These findings also indicated that whereas there was no socioeconomic gradient in attempts to quit, success with quitting was highest among those with the most socioeconomic resources. 3 These disparities reflect larger structural forces that shape the social context of people’s lives—the fabric and texture of day-to-day experiences and realities. Social context includes an array of social and material factors that ultimately have profound effects on health and health behaviors. 4– 6 For example, results of the Alameda County Study demonstrated that behaviors such as smoking are associated with low income and cluster with social-contextual factors such as unemployment, lack of social support, living in unsafe neighborhoods, and having unmet needs for food and medical care. 6 Similarly, Graham 5, 7 reported that social-contextual factors associated with low income are particularly relevant for smoking patterns. She concluded that different factors influence patterns of tobacco use among low-income women relative to women in the middle and upper classes. For low-income women, smoking may be used as a means of coping with economic pressures and the resulting demands placed on them to care for others. Graham categorized these influences as including everyday responsibilities, such as child care and patterns of paid work; material circumstances, including housing, debt load, and access to a car; social support and social networks; and personal and health resources, including patterns of health-related behavior and alternative coping strategies. Even among low-income women, smoking rates were associated with having fewer resources and greater role responsibilities such as work responsibilities and child care. To date, little research has been conducted to develop effective methods to reduce class-based disparities in tobacco use. We present a social-contextual model for understanding the influence of socioeconomic position on smoking patterns, apply this model to worksite-based smoking cessation efforts among blue-collar workers, and suggest avenues along which future research may be guided by this model. We incorporate a range of social and behavioral theories and lessons from social epidemiology to explicate the social-contextual pathways by which socioeconomic position may influence tobacco use. 8– 13 Socioeconomic position may be defined as a social relationship premised on people’s structural location within the economy 14 ; it determines one’s prospects in life, exposures to life stressors, and access to social, educational, and economic resources. 15 We focus particularly on occupation to identify approaches to reducing tobacco use among workers in the lowest occupational ranks. These positions include those traditionally defined as “blue collar,” including crafts and kindred occupations, operatives, transportation operatives, and laborers. Illuminating the pathways by which occupation may influence tobacco use patterns, will perhaps make it possible to improve the relevance and efficacy of tobacco control interventions for blue-collar workers.
