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 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 exploring heterogeneity in the smoking-health relationship between social groups. Logistic regression analyses were performed using data from the 1992-93 Santé Quebéc survey, a weighted random sample of the non-institutionalized population of the province of Québec, Canada (N = 23,564). The findings suggest that the likelihood of reporting health as poor or fair was greater for smokers 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, evaluation and implementation of health care programmes need to pay greater attention to the interface between social, behavioural and clinical determinants of health.