Heterogeneity in the Determinants of Health? An Empirical Analysis of the Smoking-Health Relationship in Socioeconomic Context

Systematic variations in health and illness among social groups have persisted and, in some cases increased, in many countries in spite of improvements in the availability of, and access to, health care services. Health policy makers have responded by showing increasing interest in non-clinical determinants of health as a way of explaining the observed systematic variations 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 adopting a framework in which the impact of one determinant may be dependent upon the presence, absence or level of other determinants (that is, interactions), thus creating a set of complementary ‘inputs’ to health production. To test the proposed framework, logistic regression analyses were performed using data from the 1992-93 Santé Québec survey (N = 21454). The findings suggest that the socioeconomic variables are ‘effect modifiers,’ and the association between smoking and health cannot be assessed without reference to a specific value (category) of the socioeconomic variable. These findings, although preliminary, will be of importance for the development of strategic plans, policy development and programme management in the area of population health.