Sociodemographic inequalities in cigarette smoking, alcohol drinking and simultaneous use of cigarettes and alcohol among Polish farmers: findings from a questionnaire survey conducted among patients of a voivodeship farmers’ rehabilitation centre in Poland

INTRODUCTION

Tobacco use, mainly cigarette smoking, and alcohol drinking are among the most common unhealthy behaviours and substantially contribute to the health burden worldwide, in Europe and in Poland [1, 2].
The 2019 Global Burden of Disease analyses estimate that globally over 1.3 billion of people use tobacco, including 1.14 billion who currently smoke cigarettes [3, 4]. In Europe, the population of adult tobacco smokers exceeds 200 million [5]. In Poland, the number of current adult smokers is estimated at approximately 8.5 mil- lion [5, 6]. The global burden of smoking-attributable diseases is immense. It mostly includes the mortality from cancer, cardiovascular (CVDs) and lung diseases, along with related psychological and behavioural disorders [3]. In 2019, tobacco smoking caused almost 8 million deaths, mostly premature, and 200 million disability- adjusted life-years [3]. For several decades, smoking has been the major single cause of premature mortality in men, contributing now to 20% of deaths in the male po­pulation [7] and in the past 30 years (1990-2019] to more than 200 million deaths worldwide [3]. In Poland, 85,000 people aged 35 and over died from smoking- attributable diseases in 2015 – 46,000 prematurely [6, 7].
The World Health Organization (WHO) estimated that in 2019 approximately 2.5 billion adults (aged 15+) worldwide used alcohol beverages, 400 million (7%) had alcohol use disorders and 209 million (3.7%) were addicted to alcohol [2, 8]. In the European Union, around 289 million adults drank alcohol in 2019 [2]. In Poland, the number of current adult (aged 18+) alcohol drinkers in 2019 was estimated at 18 million (56%) and those who drank alcohol daily at 2.6 million (8%) [9, 10]. Worldwide, around 2.6 million deaths were caused by alcohol consumption in 2019 [2]. Alcohol has mostly contributed to CVDs, cancer, liver diseases, the health problems in pregnant women and children, injuries and accidents, and psychological and behavioural disorders [2, 11-13]. In the European Union, approximately 240,000 deaths were estimated as alcohol-attributable in 2019 [2]. In Poland, increasing alcohol consumption is one of the major causes of the public health crisis [14]. The WHO estimated the number of alcohol-attributable deaths in Poland in 2021 at 30,000 deaths [2].
The use of both substances, cigarettes and alcohol, and its health consequences shows substantial variation in geographic areas and demographic, social and economic groups [2, 15-17]. In the past, the best predictors of tobacco smoking and alcohol drinking were sex, age and sociocultural determinants [18, 19]. Currently, the largest differences in cigarette smoking and alcohol drinking result from the level of education and economic status [6, 9, 20-22], especially when extreme categories of social status are compared [23]. Recently, the fastest increase in the prevalence of cigarette smoking and alcohol drinking has been observed in low- and middle- income countries [2, 24]. Place of living, especially in women, is another social factor that may strongly determine smoking and alcohol drinking behaviours [25-27]. In Poland, the prevalence of cigarette smoking in women living in rural areas doubled in the past 30 years and might have an important impact on the smoking-related health burden in this gender and social group [6].
Therefore, there is an urgent need to monitor and evaluate the prevalence of cigarette smoking and alcohol drinking in farmers and examine the role of demographic and social determinants that may influence farmers’ smoking and alcohol drinking behaviours, with particular focus on simultaneous use of these psychoactive and harmful substances. This study aimed to analyse these behaviours and their sociodemographic predictors in depth.

MATERIAL AND METHODS

STUDY DESIGN

The current research was part of a general study on health condition and health behaviours of farmers and their families. The study has been conducted in the KRUS Farmers’ Rehabilitation Centre in Jedlec for over ten years among all patients who participated in a 21-day rehabilitation course at its start. The gene­ral study is based on a questionnaire asking farmers about different aspects of their health status, treatment of selected diseases, health behaviours and sociodemographic and economic features. Our research analysis is based on the results of the general questionnaire study and refers to all patients who participated in the abovementioned rehabilitation courses between August 2021 and September 2022.
The KRUS Farmers’ Rehabilitation Centre in Jedlec is located near the town of Kalisz in Wielkopolska voivodeship, in western Poland. The centre is one of the seven KRUS Farmers’ Rehabilitation Centres in Poland. Every year, about 13,000 farmers are treated there, including over 2,000 patients treated in the Jedlec centre. All farmers’ rehabilitation centres are financed from the farmers’ social insurance system (KRUS) that was legally enforced by the Sejm of the Republic of Poland on 20 December 1990¹.

STUDY POPULATION

Table 1 refers to demographic and social characteri­stics of study subjects. In total, 612 farmers took part in the study, including 330 women and 282 men. Among all study subjects, 53.9% were women, 62.4% were middle aged (50-59) and 61.1% had low education (primary and/or basic vocational).
Among men participating in the study, 17.7% were aged 49 or less, 53.2% aged 50 to 59, and 29.1% aged 60 and over. Most male patients had low education (66.7%) while the percentage of those with moderate (28.3%) and, in particular, high education (5%) was much lower. Among women, 23.6% were aged 49 or less, 70.3% were aged 50 to 59, and only 6.1% were in the oldest age category (60+). 56.4% of female farmers had a low education level, while 34.8% had moderate and 8.8% high education.
In both gender groups, patients in middle age and with low education predominated. However, there were substantial gender differences in demographic and social characteristics of study subjects. Compared to female subjects, men had a much higher percentage in the oldest age group (29.1% in men vs. 6.1% in women) and a lower percentage of those aged 50 to 59 (53.2% vs. 70.3%, respectively). In comparison with women, a higher proportion of men was also noted among subjects with low education (66.7% vs. 56.4%).

STUDY QUESTIONNAIRE

The self-reported, voluntary and anonymous questionnaire included single and multi-choice questions on self-esteemed health status, past or current diseases and their symptoms, past accidents and their impact on health, previous disease treatment, selected health parameters (for example, blood level of cholesterol, body mass index, blood pressure and hypertension) and major health behaviours, including tobacco use, alcohol drinking, dietary habits and physical activity [see full version of the questionnaire in annex to 28]. Questions on phy­sical activity were an extensive part of the study questionnaire and based on a short version of the International Physical Activity Questionnaire (IPAQ) [see 29]. A separate part of the questionnaire referred to physical, demographic, social and economic characteristics of study subjects. It included questions on weight and height, sex, age, level of education, place of residence (in geographical and administrative terms), type of work most often performed, and type and size of household. The date of questionnaire completion, including day, month and year, was also recorded.

MEASUREMENTS

Cigarette smoking
The study questionnaire included several questions on cigarette smoking, the use of other tobacco products and electronic cigarettes: 1) on current cigarette smoking, 2) on quitting attempt in the past 12 months, 3) on average number of cigarettes smoked a day in the past month, 4) on current use of nasal snuff, 5) on average frequency of daily use of nasal snuff in the past month, 6) on current use of e-cigarettes. Our analysis is based on the question on current cigarette smoking (“Do you smoke cigarettes? 1. Yes, 2. No”). Behavioural characteristics of cigarette smoking and, if possible, the use of nasal snuff and e-cigarettes will be a subject of additional analysis and a separate scientific paper.

Alcohol drinking
The study questionnaire included several questions on alcohol drinking: 1) on current alcohol drinking, 2) on type of alcohol consumed, 3) on size of bottles most frequently used when drinking alcohol, 4) on volume of beer, wine or vodka drunk, 5) on intensity of alcohol drinking (any type of alcohol) in the past month, 6) on alcohol consumption during weekends (Saturday and Sunday) only. The analysis below refers to the question on current alcohol drinking (“Do you drink alcohol? 1. Yes, 2. No”). A detailed analysis of alcohol drinking is planned for a separate scientific paper.

>Behavioural patterns of simultaneous use of cigarettes and alcohol
Our analysis also focused on different behavioural patterns of simultaneous use of smoking and alcohol drinking behaviours. Simultaneous use of cigarettes and alcohol does not mean cigarette smoking and alcohol drinking at the same time, but it may also often happen. It only refers to behaviours of those persons who currently smoke cigarettes and drink alcohol. Using the abovementioned questions on current cigarette smoking and alcohol drinking, four behavioural patterns of simultaneous use of cigarettes and alcohol by farmers were created and analysed by selected sociodemographic determinants: 1) farmers who simultaneously smoke cigarettes and drink alcohol (dual users), 2) farmers who smoke cigarettes but do not drink alcohol, 3) farmers who do not smoke cigarettes but drink alcohol, and 4) farmers who neither smoke cigarettes nor drink alcohol (dual abstainers).

Sociodemographic variables
As mentioned in the section on the study questionnaire (see above), the questionnaire included questions on various demographic, social and economic features of respondents. Among them, only three (sex, age and education) were chosen to be cross-sectionally analysed as potential determinants of current cigarette smoking, current alcohol drinking and behavioural patterns of simultaneous use of cigarettes and alcohol. Unfortunately, the question on personal or household income, which is considered in many studies as a strong predictor of tobacco use and alcohol drinking [20, 21, 23], was not included in the study questionnaire. Therefore, we could not evaluate whether the economic situation of subjects had an impact on their cigarette smoking and alcohol drinking. Due to the small number of respondents in particular age and education categories, primary categories of age and education were merged: for age into < 49 years, 50-59 years and 60+ years, and for education into low, moderate and high levels of education. A low level of education was defined as having completed primary and/or basic vocational education, a moderate level as general and/or vocational secondary education, and a high educational level as post-secondary and/or university or higher education, for example doctorate.

STATISTICAL ANALYSIS

The paper was based on analysis of cross-sectional questionnaire data. Results of the analysis are presented in tables and include data on the prevalence of dependent variables in selected sociodemographic categories, relevant numbers of study subjects who fulfilled analytical criteria, and values of performed statistical tests. All data were analysed using IBM SPSS Statistics version 29.0.1.0. Univariate statistical analysis was based on results of Pearson’s and Cramer’s c² tests. Pearson’s c² test was used to evaluate the relationship between two nominal variables: dependent (cigarette smoking or alcohol drinking or simultaneous cigarette smoking and alcohol drinking) and independent (sex, age and level of education). The association was considered to be statistically significant if the p-value was < 0.05. Significant p-values are bolded in tables. Cramer’s V test measures the strength of association between two nominal variables. It was assumed that V < 0.3 means a weak association, V < 0.5 a moderate association and V > 0.5 a strong association.

RESULTS

PREVALENCE OF CIGARETTE SMOKING BY SOCIODEMOGRAPHIC DETERMINANTS

Table 2 describes data on prevalence of cigarette smoking among study subjects by selected sociodemographic determinants. Among all studied farmers, 20.9% currently smoked cigarettes, 23.4% in men and 18.8% in women.
Age was found to be a significant demographic predictor for the prevalence of current cigarette smoking among male and female farmers participating in the study (p = 0.003). However, the strength of asso­ciation between age and cigarette smoking was moderate (Cramer’s V test = 0.304). In women, older study subjects were characterized by lower percentages of current cigarette smoking. The prevalence of current cigarette smoking was 16.4% in women aged 49 or less, 9.9% in women aged 50-59 years and only 2.9% among the oldest women (aged 60+). In men, the same age pattern of ciga­rette smoking was not found; the prevalence of current cigarette smoking was the highest among the oldest male farmers (17.6%) and the lowest in male farmers aged 50 to 59 (8.4%).
The study results clearly show that the prevalence of current cigarette smoking was negatively associated with education. The higher the level of education was, the lower was the percentage of farmers currently smoking cigarettes. This pattern concerned all study subjects, both men and women. Among all farmers, 24.6% of those with low education smoked cigarettes, 17.4% of those with moderate education and 4.7% of those with high education. Although differences in prevalence of current cigarette smoking in all educational groups were substantial, the abovementioned association was not found to be statistically significant (p = 0.825, Cramer’s V test = 0.055). It probably resulted from the very low number of study subjects with high education (n = 2).

PREVALENCE OF ALCOHOL DRINKING BY SOCIODEMOGRAPHIC DETERMINANTS

Table 3 includes data on the prevalence of current alcohol drinking among study subjects by selected sociodemographic determinants. Among all farmers participating in the study, 34.8% currently drank alcohol. The prevalence of alcohol drinking was over 2-fold higher in men (51.1%) than in women (20.9%).
Like for cigarette smoking, the association between farmer’s age and current alcohol drinking was found to be statistically significant (p = 0.001) and moderately strong (Cramer’s V test = 0.321). However, the age patterns of alcohol drinking differed between gender groups. Among female farmers, the percentage of current alcohol drinkers was substantially lower in old persons (aged 60+). In this age group, only 2.9% currently drank alcohol, whereas the prevalence of current alcohol drinking in women aged 50 to 59 (12.8%) and aged 49 or less (13.3%) was over 4 times or even almost 5 times higher, respectively.
Also, level of education was a significant predictor of current alcohol drinking (p = 0.041) in farmers, although the strength of this association was weak (Cramer’s V test = 0.173). Among male farmers, the association seemed to be negative – the prevalence of alcohol drinking tended to increase as the level of education decreased. Among male farmers with high education, 18.6% currently drank alcohol, in those with moderate education this percentage increased to 21.5%, and among farmers with low education it reached the highest value – 25.1%. Among female farmers, the percentage of alcohol drinkers was the highest in those who were moderately educated (16.4%) and approximately 2-fold lower both among those with low (8.8%) and high education (9.3%).

PREVALENCE OF SIMULTANEOUS USE OF CIGARETTES AND ALCOHOL BY SOCIODEMOGRAPHIC DETERMINANTS

Table 4 shows the association between simultaneous cigarette smoking and alcohol drinking among studied farmers and their sociodemographic characteristics. Among all farmers, the largest group comprised dual abstainers (53.3%) – those who neither currently smoked cigarettes nor drank alcohol. However, it means that almost 47% of farmers were current cigarette smokers, alcohol drinkers or smoked cigarettes and drank alcohol simultaneously. The percentage of farmers who currently drank alcohol but did not currently smoke cigarettes was 2-fold lower (25.5%) than the percentage of dual abstainers. Almost 5-fold lower was the percentage of farmers who currently smoked cigarettes but did not drink alcohol (11.6%). The lowest proportion of farmers was that of dual current users of cigarettes and alcohol (9.3%).
A statistically significant (p = 0.001) and moderately strong association (Cramer’s V test = 0.317) was found between simultaneous cigarette and alcohol use and gender group. Male and female farmers differed very much in their cigarette smoking and alcohol drinking behaviours. The biggest difference was found among male and female farmers who were dual users of cigarettes and alcohol. The percentage of dual users of cigarettes and alcohol was 3-fold higher in men than in women. A large gender difference was also found among farmers who did not currently smoke cigarettes but simultaneously drank alcohol (36.5% in men vs. 16.1% in women). Women were characterized by a higher percentage of dual abstainers (65.2%) than men (40.1%). The same pattern concerned farmers who currently smoked cigarettes but did not drink alcohol (13.9% of women vs. 8.9% of men).
Age was also a strong predictor for simultaneous cigarette smoking and alcohol drinking. The association was statistically significant (p = 0.001), but weaker than for gender (Cramer’s V test = 0.154). As in gender groups, patterns of simultaneous cigarette smoking and alcohol drinking in farmers varied among age groups. The percentage of dual users was higher (13.7%) among the oldest farmers (aged 60+) than in farmers aged 49 or less (8.6%) or aged 50 to 59 (8.4%). The percentage of farmers who did not smoke cigarettes but drank alcohol seemed to increase with age. This proportion was the lowest among farmers aged 49 or less (21.1%), slightly higher among those aged 50 to 59 (24.1%) and the highest among the oldest farmers (36.3%). In contrast to the abovementioned age groups, the percentage of farmers who smoked cigarettes but did not drink alcohol tended to decrease with age and was 20.3% in the youngest analysed age group (49 years or less), 9.9% in middle aged farmers (50-59 years old) and 6.9% among the oldest ones (aged 60+). The percentage of dual abstainers was the highest (57.3%) among farmers aged 50 to 59 and lower in farmers aged 49 or less (49.2%) and in the oldest farmers (43.1%).
The association between simultaneous current cigarette smoking and alcohol drinking and level of education was also statistically significant (p = 0.027) but weaker (Cramer’s V test = 0.136) than calculated for gender and age. It was probably caused by a lack of or very low number of highly educated study subjects, especially among dual users of cigarettes and alcohol (n = 0) and those farmers who smoked cigarettes but did not drink alcohol (n = 7). Therefore, it was difficult to interpret data on dual use of cigarettes and alcohol by farmers in specific educational groups. However, the percentage of dual use of these substances among studied farmers seemed to be low (at 9-10%) compared with other behavioural patterns. On the other hand, the study provided important data on the percentage of dual abstainers among farmers. This proportion was the highest among all educational groups and tended to increase with increasing level of education (51.6% for farmers with low education, 53.3% for those with moderate education and 67.4% among farmers with high education. In contrast, the percentage of farmers who smoked cigarettes but did not drink alcohol seemed to decrease with increasing level of education (20.3%, 9.9% and 6.9%, respectively). However, it should be pointed out that the calculation for highly educated farmers was based on a small number of study subjects. The proportion of farmers who did not smoke cigarettes but drank alcohol was similar in all analysed educational groups (ranging from 23.8% to 28.2%).

DISCUSSION

The current study is part of a broader, ongoing research project on the health status and health behaviours of farmers that is also planned to be continued in future. There is both a need and an opportunity to establish, observe and analyse the cohort of farmers in a longitudinal study on their health behaviours, including cigarette smoking and alcohol drinking, including in the context of the association with health perception and health condition. The results of the study also concern phenomena (smoking and alcohol drinking) which are not very often correlatively analysed in studies on farmers’ health, although both health behaviours are scientifically proven major causes of the health burden in the general and farmers’ population [25-27]. This especially concerns the lack of studies or research analyses on the simultaneous use of cigarettes and alcohol (poly-substance abuse) among Polish farmers [6, 9]. Moreover, the study questionnaire is based on a validated version of an international questionnaire (IPAQ) that is frequently used in health studies [29].
However, there are also methodological limitations that have to be taken into consideration when interpreting the study results. First, the results of the study were exclusively based on a self-reported questionnaire. It means that the results describe farmers’ self-reported health behaviours rather than actually observed health behaviours. This could increase the risk of possible discrepancies between respondents’ answers and the actual state of behavioural patterns. The self-reported formula of the questionnaire could also decrease the quality of questionnaire administration and increase the number of blank answers, especially when the questions could be considered as “too sensitive” or “socially stigmatizing” by respondents. In particular, it might concern a specific group of respondents such as women, in particular pregnant or sick persons, and might occur in specific circumstances of the questionnaire completion such as the health care setting. Therefore, secondly, it is worth clarifying that all study subjects were recruited from those farmers who expressed the will to be treated and rehabilitated and were participating in rehabilitation courses. Such respondents are usually more aware of health risks, including smoking and alcohol drinking, and tend to be less often smokers and alcohol drinkers than farmers in general. Moreover, the study questionnaire was completed in a health institution, on the first day of a pro-health event (rehabilitation course), which could increase the number of false questionnaire answers. Third, data used in the statistical analysis were based on a relatively small number of famers (N = 612), mostly living only in one region of Poland (Wielkopolska voivodeship), and were not weighted to the population of all Polish famers, so these data could not be treated as representative for health behaviours of all farmers in Poland. Fourth, the distribution of study subjects by age and education substantially differs from the age and education structure of the general farmer population in Poland [30]. In our study, farmers aged 50 to 59 were overrepresented, while young farmers [18, 30] and those with high education were underrepresented [28] (Table 1). The results of nationwide surveys conducted in Poland show that adult Poles aged 50-59 are among the most frequent smokers and alcohol drinkers [10, 31], and those who are young, with high education and living in rural areas are among the least frequent smokers and alcohol drinkers [10, 27, 31]. In fact, the small number of study subjects with high education makes it difficult to reliably interpret the prevalence of current smoking and alcohol drinking among highly educated farmers.
The prevalence of current cigarette smoking among farmers found in our study is substantially lower in both gender groups (23.4% in men and 18.8% in women) than smoking prevalence observed in recent nationwide questionnaire survey data on attitudes toward smoking in Poland. In 2019, according to data from a national survey conducted on a representative sample of adults (15 years old and over) by the Chief Sanitary Inspectorate, 31% of male farmers and 35% of female farmers smoked tobacco daily [31]. These data may even be underestimated, as they concern daily smoking, while data from our study measure current smoking, which includes both daily and occasional smoking (1-2% in Polish adults) [31]. Nevertheless, the even lower, although underestimated, proportion of cigarette smokers in farmers participating in our study seems to be high when compared with smoking among farmers in other countries [26]. It is now close to the level of current smoking characterising all adults in Poland (24% in men and 18% in women) [31]. Since the prevalence of current smoking among Polish female farmers and women living in rural areas increased almost two-fold between 1974 (it was about 10% at that time) and 2019 [6, 31], living in a rural area or being a farmer no longer protects a woman from smoking. The level of current smoking in men and women found in our study is also high enough to contribute to many smoking-attributable diseases in farmers, especially when the prevalence tends to substantially increase over a long time. The sharp increase in smoking prevalence among women living in rural areas is probably one of the reasons why lung cancer mortality has increased in all women for many years and has been the leading cancer mortality in the female population since 2007 [6]. However, it requires additional research analysis based on long-term aggregated data on smoking prevalence, its behavioural patterns and standardized lung cancer mortality rates.
Although the prevalence of current smoking by age and education found in farmers participating in our study differs from the level observed in Polish nationwide surveys, the age and educational patterns of current smoking in the study on farmers seem to be consistent with the patterns found in national studies, especially in women [27, 31]. Similar smoking patterns are also found in foreign studies conducted in rural areas [26]. In general, the prevalence of current smoking has the highest level in young adult women, including farmers, and tends to decrease with increasing age, while in men this pattern is not observed. In surveys based on sufficiently large, random and representative samples, smoking prevalence usually remains high in people with low education and decreases with the increasing level of education [27]. However, as underlined above, we have to carefully interpret educational patterns of smoking in our study, because of the “small numbers bias” in highly educated farmers.
The prevalence of current alcohol drinking found among farmers in our study (34.8% for all study subjects, 51.1% in men and 20.9% in women) seems to be substantially underestimated. First of all, it results from methodological limitations of the study mentioned above. Results of the nationwide questionnaire survey on alcohol drinking conducted in 2022 by the State Agency for Prevention of Alcohol-Related Problems on a representative sample of 2,000 adult Poles indicate much higher prevalence of alcohol drinking both in the general population (76.1% in men, 84% in women) and among people living in rural areas (81.5%) than in farmers participating in our study [10, 32]. First of all, it may result from the abovementioned metho­dological limitations of the study on farmers, mainly from recruitment of respondents who were more aware of the health risk of alcohol drinking and the circumstances in which the study questionnaire was completed (health care setting), which might have an impact on lower alcohol drinking rates among studied farmers (see the section above on study strengths and limitations). Moreover, the high rates of alcohol drinking observed in the 2020 survey might result from changes in mental health (e.g. stress, anxiety, sleep disturbances, social isolation) and weakening the alcohol prevention and treatment programmes and services during the COVID-19 epidemic [33, 34]. Although there are substantial differences in the prevalence of alcohol drinking between our study and the results of the nationwide Polish surveys on alcohol use, the age pattern of alcohol drinking seems to be consistent in both studies – the older the age of adults, the higher the alcohol drinking rates. However, the same similarities were not found in analysed studies for educational patterns of alcohol drinking.
The present analysis of simultaneous use of cigarettes and alcohol by farmers is unique in Polish studies, in particular when made in specific age and educational groups. The results of our study show that almost 47% of farmers smoke cigarettes, drink alcohol or are dual users of both psychoactive substances. Due to the reasons described above, this percentage might even be underestimated. The percentage of farmers who simultaneously smoke cigarettes and drink alcohol (9.3%, including 14.5% of men and 4.8% of women) also seems to be underestimated. However, it means that large numbers of Polish farmers, mostly men, are exposed to toxic and carcinogenic compounds contained in both tobacco smoke and alcohol. It may contribute to the greater frequency and severity of health consequences than those observed in farmers who are exposed to only one of these unhealthy substances [35]. Moreover, poly-substance abuse may increase addiction symptoms and impede treatment of tobacco and alcohol dependence. It also requires more intensive and specific cessation interventions, programmes and services [36].

CONCLUSIONS

The prevalence of cigarette smoking and alcohol drinking still remains high among Polish farmers. One in ten farmers simultaneously smokes cigarettes and drinks alcohol. Only half of farmers currently abstain from cigarettes and alcohol. It may contribute to serious psychological and somatic health problems among farmers, requiring in-depth investigation. All abovementioned dependent variables are strongly determined by farmers’ sociodemographic status. A strong association was found with gender, age and the level of education. Diffe­rences in gender and age groups seem to be larger for current alcohol drinking. Differences in educational groups tend to be larger for current cigarette smoking. These social inequalities should be seriously considered when developing targeted tobacco and alcohol preventive and cessation programmes for farmers in order to effectively change their health status and health behaviours.

DISCLOSURE

MP, MB and EW report no conflict of interest. KP reports collaboration and consultancies with pharmaceutical companies: Adamed Pharma SA and Aflofarm Farmacja Sp. z o.o.

References