University of Groningen
Trends in smoking, diet, physical exercise, and attitudes toward health in European
university students from 13 countries, 1990-2000
Steptoe, A; Wardle, J; Cui, WW; Bellisle, F; Zotti, AM; Baranyai, R; Sanderman, Robbert;
Bellisie, F
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Preventive Medicine
DOI:
10.1006/pmed.2002.1048
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Steptoe, A., Wardle, J., Cui, W. W., Bellisle, F., Zotti, A. M., Baranyai, R., ... Bellisie, F. (2002). Trends in
smoking, diet, physical exercise, and attitudes toward health in European university students from 13
countries, 1990-2000. Preventive Medicine, 35(2), 97-104. DOI: 10.1006/pmed.2002.1048
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Preventive Medicine 35, 97–104 (2002)
doi:10.1006/pmed.2002.1048
Trends in Smoking, Diet, Physical Exercise, and Attitudes
toward Health in European University Students
from 13 Countries, 1990 –2000 1
Andrew Steptoe, D.Phil.,* ,2 Jane Wardle, Ph.D.,* Weiwei Cui, M.Sc.,* France Bellisle, Ph.D.,†
Anna-Maria Zotti, Ph.D.,‡ Reka Baranyai, M.D., Ph.D.,§ and Robert Sanderman, Ph.D. ¶
*Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, United
Kingdom; †INSERM U341, Service de Diabetologie, Hotel-Dieu, Paris, France; ‡Scuola Universitaria di Psicologia Applicata,
University of Turin, Torino, Italy; §Institute of Behavioural Sciences, Semmelweis University of Medicine, Budapest, Hungary;
and ¶Northern Centre for Healthcare Research, University of Groningen, Groningen, The Netherlands
INTRODUCTION
Background. Smoking, diet, and physical exercise
are key determinants of health. This study assessed
changes over 10 years and their relationship to
changes in health beliefs and risk awareness.
Method. A survey was carried out of university students from 13 European countries (Belgium, England,
France, Germany, Greece, Hungary, Iceland, Ireland,
Italy, The Netherlands, Poland, Portugal, and Spain)
in 1990 (4,701 men, 5,729 women) and repeated in 2000
(4,604 men, 5,732 women). We assessed smoking, exercise, fruit and fat intake, beliefs in the importance of
behaviors for health, and awareness of the influence of
behaviors on heart disease risk.
Results. Smoking prevalence increased and fruit
consumption decreased between 1990 and 2000, while
physical exercise and fat intake were more stable.
There were large variations between country samples.
Health beliefs weakened, with marked decreases in
beliefs about smoking and diet. Across country samples, changes in beliefs correlated with changes in the
prevalence of behaviors. Awareness of the effects of
smoking and exercise was stable, but knowledge of the
role of fat intake increased over the decade.
Conclusions. The differences in health behaviors, beliefs, and risk awareness between the two surveys
were disappointing in this educated sector of young
adult Europeans. The association between changes in
beliefs and prevalence of behavior emphasizes the importance of enhancing positive attitudes to healthier
lifestyles. © 2002 American Health Foundation and Elsevier Science (USA)
Key Words: health behavior; health beliefs; risk
awareness; international health.
Tobacco smoking, diet, and physical exercise are key
aspects of lifestyle that influence the risk for the major
diseases of affluent societies such as cancer and coronary heart disease. Lifestyles and health beliefs appear to be established early in life, setting the pattern
for later years [1,2]. It is important, therefore, to monitor the trends in health behavior in young people, and
to understand the factors such as risk awareness and
beliefs that might impact on the uptake of health behavior. International comparisons are particularly
valuable, since they delineate variations in behavioral
risk in different cultures, point to common determinants, and help to highlight good practice in preventive
medicine.
The European Health and Behaviour Study (EHBS)
was a survey of health behaviors and associated attitudes carried out with 16,483 university students from
21 countries between 1989 and 1991 [3,4]. Large international variations were identified in the levels of
smoking [5], exercise [6], and healthy dietary practices
[7]. Women smoked less and had healthier diets than
men, but exercised less. Health behaviors were closely
associated with health beliefs, but knowledge of the
role of behavior in disease risk varied widely, and was
inconsistently associated with behavior.
Since the EHBS was carried out, there has been a
growing acknowledgment of the influence on disease
risk of lifestyle [8,9]. We therefore repeated the survey
in 13 of the participating countries after an interval of
10 years, to identify trends in major health behaviors
and associated beliefs. We also investigated whether
changes in health beliefs in the different countries over
the decade were associated with trends in behavior.
Beliefs in the benefits to health of carrying out health
practices are central to many models of behavior
1
This research was supported in part by the Economic and Social
Research Council, United Kingdom.
2
To whom reprint requests should be addressed. E-mail:
[email protected].
97
0091-7435/02 $35.00
© 2002 American Health Foundation and Elsevier Science (USA)
All rights reserved.
98
STEPTOE ET AL.
change [10]. We hypothesized that countries in which
beliefs increased or decreased on average over the decade would show corresponding changes in the prevalence of health behaviors.
METHOD
Study Design and Sample
The EHBS was carried out between 1989 and 1991
[4]. The new survey, the International Health and Behaviour Survey (IHBS), is a study of health behaviors
in university students from 23 countries, carried out
between 1999 and 2001, using measures based on the
EHBS. The data presented here are from the 13 countries that were included in both studies. In this report,
results from the EHBS are referred to as 1990 data,
while results from the IHBS are referred to as 2000
data.
In common with the majority of studies of health
behavior, data were collected by self-report questionnaire. We used an assessment protocol that was translated and back-translated into the 11 languages included in these analyses to ensure common meanings,
with a standard scoring and data management system.
The short- and long-term reliability of measures has
been described previously [3,11]. The network of collaborators aimed for a common method of data collection, which involved asking classes of students to complete the questionnaire during a teaching session.
Participation was voluntary, but few students failed to
complete the survey instrument, ensuring a high response rate (over 90%) in most countries. Data were
analyzed from students aged 17–30, studying nonhealth-related courses. The universities surveyed were
the same in 1990 and 2000 in most countries. The total
sample analyzed was 20,776 (9,305 men and 11,471
women), divided as follows: Belgium: 1,223 (1990) and
536 (2000); England: 721 and 847; France: 657 and
771; Germany: 791 and 730; Greece: 674 and 794;
Hungary: 756 and 593; Iceland: 800 and 683; Ireland:
786 and 471; Italy: 817 and 2,028; Netherlands: 749
and 687; Poland: 799 and 762; Portugal: 856 and 951;
Spain: 811 and 483.
Measures
Health behaviors were assessed with identical questions in the EHBS and IHBS. Smoking was assessed by
asking participants to endorse one of eight response
options: “I have never smoked cigarettes, not even a
puff ”; “I have only ever tried one or two cigarettes”; “I
used to smoke sometimes, but I don’t now”; “I don’t
smoke cigarettes, but smoke a pipe or cigars”; “I smoke
cigarettes but not as many as one per day”; “I usually
smoke between 1 and 10 cigarettes per day”; “I usually
smoke between 10 and 20 cigarettes per day”; “I usually smoke more than 20 cigarettes per day.” Respon-
dents were classified as current smokers if they endorsed any of the last five categories. Physical exercise
was assessed with a question, “Over the past two
weeks have you taken any exercise (e.g., sport, physically active pastime)?” Those who responded positively
were asked about what activity they had carried out
and how many times they had exercised. In the analyses described here, being physically active was defined as any exercise in the past 2 weeks. Dietary
behavior was indexed by consumption of fruit and limitation of fat intake. Participants were asked about
their frequency of fruit consumption (daily, two or
three times a week, once a week, less than once a week,
never), and whether they deliberately avoided fat and
cholesterol (yes, no). Comparisons were made between
respondents who ate fruit daily and less than daily,
and those who did and did not limit fat intake.
Beliefs in the benefits of healthy lifestyles were recorded by asking participants how important the following practices were for health maintenance on a
10-point scale from 1 ⫽ low importance to 10 ⫽ very
great importance: not smoking, taking regular exercise, avoiding fat, and eating fruit. Hungary and Italy
were excluded from the analyses of beliefs about fruit,
since the ratings concerning fruit were not obtained in
1990.
Risk awareness or knowledge was assessed as part of
a larger section of the surveys concerned with knowledge of a range of lifestyle factors relevant to health.
Participants were asked (using a yes–no format)
whether they believed that heart disease risk was affected by smoking, physical exercise, and dietary fat
intake.
Statistical Analysis
Data were analyzed using SPSS Version 10.0.5 (Chicago, IL) and STATA Version 6.0 (College Station, TX).
The prevalence of behaviors and risk awareness in
1990 and 2000 in each country were adjusted for age,
and are presented as percentages with 95% confidence
intervals (CIs). Beliefs in health benefits in each country sample adjusted for age are presented as means
with 95% confidence intervals. The significance of
changes in behavior and risk awareness over time was
calculated with separate logistic regressions within
each country, assessing the odds of engaging in the
behavior or being aware of the risk in 2000 compared
with 1990, adjusted for age. Analysis of covariance
(covarying for age) was used to assess changes in beliefs over time. The confidence intervals in analyses
aggregated across country samples were adjusted for
the clustered nature of the data using STATA. Associations between changes in behavior and beliefs across
country samples were analyzed with separate correlations for men and women, and the significance levels of
99
TRENDS IN HEALTH BEHAVIOR
TABLE 1
Prevalence of Smoking in 1990 and 2000, Adjusted for Age
Men
Belgium
England
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
Women
1990 (95% CI)
2000 (95% CI)
Change
1990 (95% CI)
2000 (95% CI)
Change
22.7% (19–27)
30.6% (25–36)
28.4% (23–34)
35.2% (31–40)
39.9% (35–45)
15.1% (11–20)
25.0% (20–30)
28.1% (23–33)
25.3% (21–30)
38.1% (32–44)
32.8% (28–37)
43.0% (38–48)
32.1% (27–37)
25.7% (21–31)
29.7% (25–34)
31.5% (27–36)
36.5% (32–42)
44.0% (40–49)
23.4% (18–29)
26.6% (22–32)
37.5% (29–47)
43.1% (40–46)
27.2% (22–33)
26.3% (21–31)
47.4% (43–52)
36.3% (30–42)
3.0%
⫺0.9%
3.1%
1.3%
4.2%
8.3%**
1.6%
9.5%
17.8%***
⫺10.9%**
⫺6.4%
4.4%
4.3%
14.9% (11–18)
29.6% (25–34)
31.3% (27–36)
32.4% (28–37)
37.3% (33–42)
15.1% (11–20)
30.6% (26–35)
34.8% (31–39)
19.6% (15–24)
26.8% (23–31)
20.9% (16–25)
38.6% (35–43)
37.5% (33–42)
19.0% (14–24)
28.8% (24–34)
34.8% (30–39)
35.8% (31–40)
42.5% (38–47)
23.9% (19–29)
29.8% (25–35)
37.1% (32–42)
35.7% (33–38)
27.2% (23–32)
25.8% (21–30)
42.5% (38–47)
46.0% (41–52)
4.1%
⫺0.8%
3.5%
3.3%
5.2%
8.7%**
⫺0.8%
2.3%
16.1%***
0.4%
4.9%*
3.9%
8.5%*
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
the correlations were combined using the Stouffer
method.
RESULTS
Prevalence of Health Behaviors in 1990 and 2000
The overall prevalence of smoking rose from 30% (CI:
25–36) in 1990 to 35% (CI: 30 – 41) in male students,
and from 28% (CI: 22–35) to 33% (CI: 29 –39) in women.
Smoking prevalence increased modestly in most country samples (Table 1), but in two cases (Hungary and
Italy) there were substantial rises in both men and
women across the decade. Smoking levels were high in
Southern European samples, with more than 40% of
men and/or women smoking in 2000 in Greece, Italy,
Portugal, and Spain. Differences between sexes
were small, and were significant only in the Italian
sample.
The prevalence of physical exercise was generally
higher in men than women (Table 2). Overall, 76% of
men and 65% of women had exercised at least once
over the past 2 weeks in 2000, compared with 72% men
and 62% women in 1990. There were increases in the
prevalence of physical exercise among both men and
women in Belgium, Greece, and Spain, among women
in Ireland, and among men in England and Poland.
Exercise prevalence decreased in women from Hungary, The Netherlands, and Poland. Across countries,
physical exercise was less common in 2000 in Portugal,
Greece, and Spain than in more northern countries,
TABLE 2
Prevalence of Physical Exercise in 1990 and 2000, Adjusted for Age
Men
Belgium
England
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
Women
1990 (95% CI)
2000 (95% CI)
Change
1990 (95% CI)
2000 (95% CI)
Change
74.1% (70–78)
66.9% (62–72)
67.8% (63–73)
81.6% (77–86)
55.5% (51–61)
87.6% (83–92)
83.9% (80–88)
70.5% (66–76)
74.2% (70–79)
84.3% (79–90)
76.7% (72–81)
52.6% (48–58)
59.3% (55–64)
86.5% (81–92)
75.3% (71–80)
74.7% (70–79)
79.5% (75–84)
70.1% (66–75)
87.5% (82–93)
78.4% (73–83)
79.0% (70–88)
74.2% (71–78)
77.2% (72–82)
87.8% (83–93)
60.4% (56–64)
76.9% (71–83)
12.5%***
8.4%*
6.9%
⫺2.1%
14.6%***
⫺0.1%
⫺5.6%*
8.5%
0.0%
⫺7.1%
11.0%*
7.8%
17.6%***
61.4% (58–65)
61.4% (57–66)
58.6% (54–63)
79.9% (75–84)
29.4% (25–34)
95.0% (91–100)
75.0% (71–80)
65.2% (61–69)
57.7% (53–62)
84.2% (80–88)
73.8% (69–78)
35.8% (32–40)
35.9% (32–40)
73.7% (68–79)
63.1% (58–68)
60.5% (56–65)
78.2% (74–83)
48.9% (45–53)
87.4% (83–92)
73.0% (68–78)
79.1% (74–84)
60.5% (58–63)
75.8% (72–80)
65.2% (61–70)
36.7% (33–41)
52.7% (47–58)
12.3%***
1.6%
1.9%
⫺1.7%
19.5%***
⫺7.6%***
⫺2.0%
13.8%***
2.9%
⫺8.4%*
⫺8.6%***
0.9%
16.8%***
100
STEPTOE ET AL.
TABLE 3
Prevalence of Eating Fruit Daily in 1990 and 2000, Adjusted for Age
Men
Belgium
England
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
Women
1990 (95% CI)
2000 (95% CI)
Change
1990 (95% CI)
2000 (95% CI)
Change
47.3% (43–51)
36.1% (31–42)
53.4% (48–59)
45.8% (41–51)
39.2% (34–45)
45.4% (41–50)
31.3% (27–36)
43.3% (38–49)
72.1% (67–77)
36.3% (30–42)
36.2% (31–41)
78.2% (73–83)
67.6% (63–73)
32.6% (27–38)
36.2% (32–41)
36.3% (32–41)
32.2% (27–37)
39.3% (35–44)
29.9% (24–36)
23.0% (18–28)
41.9% (33–51)
57.7% (54–61)
37.7% (32–43)
42.1% (37–47)
54.9% (51–59)
57.1% (51–63)
⫺14.7%***
0.1%
⫺17.1%***
⫺13.6%***
0.1%
⫺15.5%***
⫺8.3%*
⫺1.4%
⫺14.4%***
1.4%
5.9%
⫺23.3%***
⫺10.5%*
67.4% (64–71)
45.2% (41–50)
66.4% (61–71)
63.5% (59–68)
53.3% (48–58)
61.9% (57–67)
43.4% (39–48)
54.4% (50–59)
78.9% (74–84)
63.4% (59–68)
59.8% (55–65)
86.0% (82–90)
80.7% (76–85)
44.1% (38–50)
43.5% (39–49)
53.2% (48–58)
56.6% (52–61)
47.5% (43–52)
40.2% (35–45)
30.4% (26–35)
45.7% (41–51)
63.6% (61–66)
54.1% (50–59)
60.0% (55–65)
66.4% (62–71)
64.1% (58–70)
⫺23.3%***
⫺1.7%
⫺13.2%***
⫺6.9%*
⫺5.8%
⫺21.7%***
⫺13.0%***
⫺8.7%*
⫺15.3%***
⫺9.3%**
0.2%
⫺19.6%***
⫺16.6%***
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
with particularly low levels among women from Portugal (36.7%) and Greece (48.9%).
In 1990, 49% of men and 64% of women ate fruit
daily, but these fell to 42 and 54% in 2000 (Table 3).
The decrease in daily fruit consumption was significant
in both men and women from Belgium, France, Germany, Hungary, Iceland, Italy, Portugal, and Spain.
There was little change in England, Greece, or Poland,
but women reduced fruit intake in Ireland and The
Netherlands. The net result was that the Mediterranean country advantage in fruit consumption was reduced in 2000 compared with 1990.
Changes in fat intake were smaller and less consistent. Overall, 24% of men and 46% of women reported
limiting fat intake in 2000, compared with 27 and 46%
in 1990 (Table 4). Marked decreases in efforts to limit
fat intake were observed in three samples: men from
Germany, women from The Netherlands, and men and
women from Hungary.
Beliefs in Lifestyle and Health
The strength of beliefs averaged across countries
concerning the importance to health of not smoking
was 8.51 (CI: 8.32– 8.69) in 1990, falling to 8.06 (CI:
7.87– 8.26) in 2000, with significant decreases in the
samples from Belgium, Germany, Greece, Hungary,
Iceland, Italy, The Netherlands, Poland, and Portugal.
Beliefs about the importance of regular exercise remained stable overall over the decade (mean: 8.17, CI:
7.94 – 8.46, in 1990; mean: 8.08, CI: 7.87– 8.27, in
2000), but rose significantly in two (England, Iceland),
TABLE 4
Prevalence of Efforts to Limit Fat Intake in 1990 and 2000, Adjusted for Age
Men
Belgium
England
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
Women
1990 (95% CI)
2000 (95% CI)
Change
1990 (95% CI)
2000 (95% CI)
Change
23.6% (20–28)
32.1% (27–37)
20.2% (15–26)
31.1% (26–36)
30.5% (25–36)
32.9% (28–36)
20.4% (16–25)
31.0% (26–36)
31.4% (27–36)
30.0% (24–36)
23.2% (19–28)
19.5% (14–25)
26.5% (22–31)
21.7% (16–28)
31.2% (27–36)
17.6% (13–22)
18.7% (14–24)
26.6% (22–31)
20.3% (14–26)
24.9% (20–30)
27.8% (19–37)
23.7% (20–27)
22.5% (17–28)
22.9% (18–28)
21.1% (17–25)
31.4% (25–38)
⫺1.9%
⫺0.9%
⫺2.6%
⫺12.4%***
⫺3.9%
⫺12.6%***
4.5%
⫺3.2%
⫺7.7%**
⫺7.5%
⫺0.3%
1.6%
4.9%
43.2% (40–47)
53.3% (49–58)
43.8% (39–49)
46.2% (42–51)
47.5% (43–52)
43.8% (39–49)
40.4% (36–45)
50.0% (46–54)
49.5% (45–54)
54.5% (50–59)
39.6% (35–44)
40.0% (36–44)
47.7% (43–52)
46.9% (41–52)
50.2% (45–55)
39.2% (34–44)
52.5% (48–57)
45.9% (41–51)
35.1% (30–40)
49.6% (45–55)
50.9% (46–56)
47.2% (45–50)
40.7% (36–45)
45.2% (41–50)
42.2% (38–47)
52.1% (47–58)
3.7%
⫺3.1%
⫺4.6%
6.3%
⫺1.6%
⫺8.7%*
9.2%*
0.9%
⫺2.3%
⫺13.7%***
5.6%
2.2%
4.4%
101
TRENDS IN HEALTH BEHAVIOR
TABLE 5
Awareness of the Influence of Smoking (Left) and Physical Exercise (Right) on Heart Disease in 1990 and 2000 a
Smoking
Belgium
England
France
Germany
Greece
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
Physical exercise
1990 (95% CI)
2000 (95% CI)
Change
1990 (95% CI)
2000 (95% CI)
Change
56.0% (53–58)
76.2% (73–80)
60.2% (57–64)
73.4% (70–77)
72.0% (68–76)
75.2% (72–78)
70.2% (67–74)
41.2% (38–44)
75.7% (72–79)
37.1% (34–40)
60.1% (57–63)
59.8% (57–63)
58.5% (55–63)
68.2% (65–71)
49.3% (46–53)
69.9% (67–73)
81.1% (78–84)
79.7% (76–83)
76.0% (72–81)
51.2% (49–53)
71.2% (68–75)
77.8% (75–81)
54.8% (52–58)
60.9% (57–65)
2.5%
⫺8.0%***
⫺10.9%**
⫺3.5%
9.1%***
4.5%*
5.8%*
10.0%***
⫺4.5%*
40.7%***
⫺5.3%*
1.1%
36.0% (33–39)
63.9% (60–68)
51.1% (47–55)
54.6% (51–58)
38.7% (35–42)
57.3% (54–61)
52.6% (49–56)
26.8% (24–30)
71.4% (68–75)
22.4% (19–26)
40.5% (37–44)
50.6% (47–54)
59.8% (56–64)
52.4% (49–56)
47.0% (44–51)
38.5% (35–42)
65.7% (62–69)
53.2% (50–57)
47.7% (43–52)
41.6% (40–44)
64.3% (61–68)
25.8% (22–29)
35.0% (32–38)
42.6% (38–47)
23.8%***
⫺11.5%***
⫺4.1%
⫺16.1%***
27.0%***
⫺4.1%
⫺4.9%
14.8%***
⫺7.1%**
3.4%
⫺4.5%**
⫺8.0%**
a
Data adjusted for age and sex.
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
and declined in four (France, Hungary, Italy, The
Netherlands) country samples. A reduction in the perceived importance of fruit consumption was evident,
with means of 8.18 (CI: 7.85– 8.51) in 1990 and 7.73
(CI: 7.49 –7.96) in 2000. Decreases in strength of beliefs
in the importance of fruit were observed in all country
samples except Iceland and Ireland. At both time
points, students’ beliefs in the importance of limiting
fat intake were lower than for the other behaviors, but
there was also a decline overall from 6.60 (CI: 6.22–
6.97) in 1990 to 6.19 (CI: 5.88 – 6.50) in 2000; the decrease was significant in Belgium, England, Germany,
Greece, Italy, The Netherlands, Poland, and Portugal.
The correlation across countries between the change in
the strength of beliefs in the importance of not smoking
and the change in smoking prevalence was ⫺0.48 in men
and ⫺0.45 in women (combined P ⫽ 0.012). Thus countries in which beliefs declined to a greater extent showed
larger increases in the prevalence of smoking than did
those with small decreases in belief ratings. Correlations
across countries between changes in beliefs in physical
exercise and the prevalence of exercise were 0.39 for men
and 0.33 for women (combined P ⫽ 0.046). Significant
positive correlations also emerged between changes in
strength of beliefs about fruit and reported consumption
(r ⫽ 0.50 and 0.49 for men and women, combined P ⫽
0.014), and between changes in beliefs about fat and
changes in efforts to limit fat intake (r ⫽ 0.65 and 0.21 for
men and women, combined P ⫽ 0.014). Thus, for all four
behavioral indices, trends in the aggregate levels of beliefs were associated with changes in the prevalence of
healthy practices.
fat on heart disease is detailed in Tables 5 and 6. There
was little net change in the proportion of respondents
who were aware that heart disease is influenced by smoking, with overall changes from 64 to 66% over the decade
in male students and from 62 to 63% among women
(Table 5). However, this disguises substantial variations
across country samples. Awareness of the health risks of
smoking increased significantly in Greece, Iceland, Ireland, and Italy, with particularly marked increases in
Poland (40.7% rise). By contrast, fewer English, French,
Dutch, or Portuguese students were aware of the impact
of smoking on heart disease in 2000 compared with 1990.
Awareness of the influence of physical exercise on
heart disease was low in many countries, with aggregate levels of 47% (1990) and 45% (2000) in men and
48% (1990 and 2000) in women. Large increases in
awareness were observed in some countries, notably
Belgium, Greece, and Italy (Table 5). Unfortunately,
fewer students from England, Germany, The Netherlands, Portugal, and Spain were aware of the link in
2000 than in 1990.
By contrast with the other knowledge-related factors,
awareness of the influence of dietary fat on heart disease
was high, and increased over the decade. Aggregate prevalence was 73% in men and 72% in women in 1990, rising
to 85 and 84% in 2000 (Table 6). More than 90% of
respondents from Belgium, England, Iceland, Ireland,
and The Netherlands were aware, and there were significant increases in 10 of the 12 countries analyzed.
There were no significant associations between
changes in beliefs or behavior and changes in the levels
of risk awareness across country samples.
Awareness of the Influence of Lifestyle on Heart Disease
DISCUSSION
The prevalence, adjusted for age and sex, of awareness
of the influence of smoking, physical exercise, and dietary
Information concerning trends in health behavior
and attitudes over the 1990s is limited as yet. The
102
STEPTOE ET AL.
TABLE 6
Awareness of the Influence of Dietary Fat Intake
on Heart Disease in 1990 and 2000 a
Belgium
England
France
Germany
Greece
Iceland
Ireland
Italy
The Netherlands
Poland
Portugal
Spain
1990 (95% CI)
2000 (95% CI)
Change
68.8% (67–71)
93.2% (90–96)
82.0% (79–85)
74.1% (71–77)
71.4% (68–74)
82.6% (80–85)
91.0% (88–94)
36.1% (33–39)
84.0% (81–87)
59.8% (57–63)
67.3% (64–70)
70.1% (67–73)
90.2% (87–94)
90.2% (87–93)
87.3% (85–90)
89.4% (87–92)
78.3% (76–81)
91.1% (88–94)
94.5% (91–98)
75.2% (74–77)
92.9% (90–96)
89.7% (87–93)
77.5% (75–80)
83.7% (80–87)
21.4%***
⫺3.0%
5.3%**
15.3%***
6.9%**
8.5%***
3.5%
39.1%***
8.9%***
29.9%***
10.2%***
13.6%***
a
Data adjusted for age and sex.
* P ⬍ 0.05.
** P ⬍ 0.01.
*** P ⬍ 0.001.
growing prevalence of obesity in developed countries
over this period [12] points to an increasing imbalance
between energy intake and expenditure. Data from the
Behavioral Risk Factor Surveillance System in the
United States indicate a rather stable level of leisure
time physical activity between 1990 and 1998 [13],
while there have been increases in snack consumption
[14] and fat in the diet [15], and variable trends in fruit
and vegetable consumption in different sectors of the
population [16]. Smoking has declined in some populations but has remained stable in others [17]. There is
considerable concern about increasing smoking levels
among U.S. college students [18]. Few international
comparisons of health practices over this period have
been published, except in adolescents [19], so direct
comparisons with other surveys are limited. Studies of
smoking indicate wide variations in trends between
different populations and regions of Europe [20]. But
the World Health Organization’s European Health for
All database indicates that, of the countries included in
this study, the largest reduction in percentage energy
derived from fats between 1990 and 1998 was in Hungary, and the largest increase was in Spain [21]; these
countries were also at the extremes in the present
study. Additionally, the proportion of adults reporting
any leisure time physical activity in a recent comparison of national representative samples from European
countries correlated r ⫽ 0.87 (P ⫽ 0.008, n ⫽ 10)
with the prevalence of physical exercise in our 2000
survey [22].
The analyses described here show a disappointing
set of trends in the health behaviors of university students over the decade. There has been a slight increase
in physical exercise, but at the same time some increase in smoking prevalence and a marked deterioration in the frequency of fruit consumption. The sex
differences observed in the analyses of 1990 were
maintained. The countries involved in this survey span
a range of cultures, from the Mediterranean and
former communist states to Western Europe and Scandinavia. We had anticipated that increased globalization might lead to a narrowing of differences in health
behavior across country samples, but this was not generally the case. For example, the 27.9% difference
across country samples in the age-adjusted prevalence
of smoking among men in 1990 narrowed only slightly
to 24.0% in 2000. The proportion of women limiting fat
intake ranged from 39.6 to 54.5% (14.9% range) in
1990, and from 35.1 to 52.5% (17.4% range) in 2000.
Only in the case of fruit consumption was there convergence between countries over time, with the
between-country sample range falling from 46.9 to
34.7% in men and from 42.7 to 26.2% in women. The
main explanation for this effect was a reduction in fruit
intake in Mediterranean countries. In an era of sustained efforts in health promotion and health education, the behavior of young people in the privileged
sector of the population studied in this survey remains
stubbornly resistant to positive change.
The lack of progress toward healthier behavior was
coupled with a decline in the strength of beliefs about
the importance of not smoking and of maintaining a
healthy diet. It is widely agreed that attitudes and
beliefs are key determinants of health behavior [23].
However, efforts to maintain health beliefs require
constant reinforcement, since information and encouragement must be presented to each cohort of emerging
adults. It is possible that the emphasis in health education for young people on the dangers of other aspects
of lifestyle (unprotected sexual activity, binge drinking, drinking and driving, etc.) in the 1990s led to a
reduced emphasis on the perceived importance of
smoking, exercise and diet.
Despite the general trend toward weakening beliefs
in the importance to health of these behaviors, a significant association was observed between changes in
beliefs and the prevalence of healthy practices. For
each of the four behaviors studied, the change in mean
belief rating was correlated with changes in behavior
prevalence. Thus in country samples in which beliefs in
the importance of behavior were reduced, there were
larger reductions in physical exercise, fruit consumption, and efforts to limit fat intake and greater increases in smoking as well. Although causality cannot
be determined from these cross-sectional data, the results are consistent with the possibility that enhancing
beliefs in the importance of lifestyle throughout the
community might help promote healthier lifestyles.
Beliefs about the importance of behaviors are attitudinal variables, while the risk awareness measures
reflect knowledge about lifestyle and health [24]. The
changes in risk awareness in different countries were
more diverse than the changes in behavior or beliefs.
103
TRENDS IN HEALTH BEHAVIOR
For example, awareness of the influence of smoking on
heart disease increased significantly in five country
samples, but decreased in four. The changes in knowledge that physical exercise affects heart disease varied
from ⫺16.1 to ⫹27.0%. These variations may reflect
the introduction of strong new health education messages in certain countries. There have been important
developments in health education in Europe over the
1990s, with new initiatives in Belgium, Poland, and
other countries [25]. There is evidence for a growing
recognition of individual responsibility for health in
Italy which might relate to the substantial growth of
awareness of the role of smoking, exercise, and diet
among Italian students. It is particularly striking that
awareness of the effects of dietary fat on heart disease
reached near-maximum levels in several countries,
while knowledge of the benefits of physical exercise
was much lower.
The changes in prevalence of behavior across countries were not correlated with changes in risk awareness. This result was anticipated, since in this educated sector of the population, ignorance of health risks
is not a key determinant of healthy choices. We have
previously demonstrated that awareness of the health
risks of smoking is greater among smokers than nonsmokers [5].
These results are not representative of the countries
involved. Students are better educated and typically
healthier than other sectors of society [26]. Universityeducated individuals in Europe exercise more than
those with less education [22] while being less likely to
smoke and more likely to quit if they are smokers [27].
The levels of behavior summarized here therefore
present a more favorable impression of healthy lifestyle in the countries involved than would representative samples. In addition, students were not sampled
systematically from universities across each country,
so the samples may not be typical of students. The
rationale for studying students in this fashion has been
detailed elsewhere [4]. University students are a significant sector of the early adult population in which
there is concern both about health behavior and psychological well-being [18,28,29]. Since students form a
prominent sector of society from which the policy makers and teachers of future eras will be drawn, their
health-related activities are of particular interest. Social diffusion processes may lead less affluent and educated sectors of the population to take up these attitudes and behaviors in time [30]. In addition,
university students are an easily accessible, relatively
healthy sector of the population with similar educational backgrounds; this eliminates variability due to
ill health and education, both of which influence health
practices [31].
The inferences that can be drawn from this study are
limited by the cross-sectional design and by the use of
self-report questionnaires. Participants may not be reliable in the reports of their behaviors, although it is
unlikely that any biases will have changed over time.
Behaviors were assessed with summary questions, and
more detailed assessments might have yielded more
subtle patterns; nonrecreational physical exercise was
not measured, and the assessment of fat intake did not
distinguish different types of fat. Nonetheless, the
study indicates that changes over the decade in the
attitudes and behaviors of this sector of the young
population are generally not toward healthier lifestyles, and that persistent efforts are required to establish favorable health habits in youth.
ACKNOWLEDGMENTS
The following colleagues participated in the EHBS and IHBS and
contributed to data collection (locations of universities in parentheses): Belgium: Dr. Jan Vinck (Diepenbeek); France: Dr. France Bellisle and Dr. Marie-Odile Monneuse (Paris); Germany: Dr. Claus
Vögele and Dr. Gudrun Sartory (Marburg, Wuppertal); Greece: Dr.
Nicolas Paritsis and Dr. Bettina Davou (Ioannina, Athens); Hungary: Dr. Maria Kopp and Dr. Árpad Skrabskı́ı (Budapest); Iceland:
Dr. Erlendur Haraldsson and Dr. Sigurlina Davidsdottir (Reykjavik); Ireland: Dr. Ray Fuller (Dublin); Italy: Dr. Anna Maria Zotti
and Dr. Giorgio Bertolotti (Turin); The Netherlands: Dr. Robert
Sanderman (Groningen); Poland: Dr. Zbigniew Zarczynski, Dr. Andrzej Brodziak, and Dr. Helena Sek (Bytom, Kracow, Poznan); Portugal: Dr. Joao Justo (Lisbon); Spain: Dr. Jaime Vila (Granada).
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