Anton E. Kunst

Educational differences in smoking: international comparison

Abstract Objective: To investigate international variations in smoking associated with educational level. Design: International comparison of national health, or similar, surveys. Subjects: Men and women aged 20 to 44 years and 45 to 74years. Setting: 12 European countries, around 1990. Main outcome measures: Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. Results: In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. Conclusions: These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries.

OBJECTIVESnTwelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences.nnnMETHODSnData on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively.nnnRESULTSnA north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years).nnnCONCLUSIONSnThe results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

Gender, health inequalities and welfare state regimes: a cross-national study of 13 European countries

Background: This study is the first to examine the relationship between gender and self-assessed health (SAH), and the extent to which this varies by socioeconomic position in different European welfare state regimes (Liberal, Corporatist, Social Democratic, Southern). Methods: The EUROTHINE harmonised data set (based on representative cross-sectional national health surveys conducted between 1998 and 2004) was used to analyse SAH differences by gender and socioeconomic position (educational rank) in different welfare states. The sample sizes ranged from 7124 (Germany) to 118u2009245 (Italy) and concerned the adult population (aged ⩾16 years). Results: Logistic regression analysis (adjusting for age) identified significant gender differences in SAH in nine European welfare states. In the UK (OR 0.88; 95% CI 0.78 to 0.99) and Finland (OR 0.85; 95% CI 0.77 to 0.95), men were significantly more likely to report “bad” or “very bad” health. In Denmark, Sweden, Norway, Holland, Italy, Spain and Portugal, a significantly higher proportion of women than men reported that their health was “bad” or “very bad”. The increased risk of poor SAH experienced by women from these countries ranged from a 23% increase in Denmark (OR 1.23; 95% CI 1.08 to 1.39) to more than a twofold increase in Portugal (OR 2.01; 95% CI 1.87 to 2.15). For some countries (Italy, Portugal, Sweden), women’s relatively worse SAH tended to be most prominent in the group with the highest level of education. Discussion: Women in the Social Democratic and Southern welfare states were more likely to report worse SAH than men. In the Corporatist countries, there were no gender differences in SAH. There was no consistent welfare state regime patterning for gender differences in SAH by socioeconomic position. These findings constitute a challenge to regime theory and comparative social epidemiology to engage more with issues of gender.

Seasonal variation in mortality in The Netherlands.

STUDY OBJECTIVE--The aim was to describe the pattern of seasonal variation in all cause mortality in The Netherlands, and to analyse the contribution of specific causes of death to the winter excess of all cause mortality. DESIGN--Daily numbers of deaths in The Netherlands, by cause, were obtained for the period 1979-1987. Patterns of variation were analysed using Poisson regression. The model related the observed number of deaths to (1) the number expected for that day on the basis of person-days at risk by age and sex, (2) secular trend, and (3) first and higher order cosine terms where appropriate. MAIN RESULTS--All cause mortality has a bimodal peak in the first months of the year. After that it declines to reach a plateau in late spring. Mortality is lowest at the end of August, after which it rises steeply again. The winter excess of all cause mortality is primarily due to cardiovascular diseases (66%) and respiratory conditions (13%). Cardiovascular mortality peaks before respiratory mortality, suggesting different lag times in the effects of winter. There was an episode of exceptionally high mortality (above the normal winter excess) in early 1986, which was primarily due to cardiovascular diseases (39%) and respiratory conditions (25%). This episode was probably caused by a severe influenza epidemic, and was not followed by a compensatory lowering of mortality. CONCLUSIONS--The pattern of variation of mortality within the year suggests that it is not based on a simple relationship with climatological circumstances, because the latter fluctuate according to a less complex pattern. Cause specific data suggest an instantaneous effect of winter on the cardiovascular system, and a delayed effect mediated by respiratory infections.

Air pollution, lagged effects of temperature, and mortality: The Netherlands 1979-87.

OBJECTIVE--To explore whether the apparent low threshold for the mortality effects of air pollution could be the result of confounding. DESIGN--The associations between mortality and sulphur dioxide (SO2) were analysed taking into account potential confounding factors. SETTING--The Netherlands, 1979-87. MEASUREMENTS AND MAIN RESULTS--The number of deaths listed by the day on which the death occurred and by the cause of death were obtained from the Netherlands Central Bureau of Statistics. Mortality from all causes and mortality from four large groups of causes (neoplasms, cardiovascular diseases, respiratory diseases, and external causes) were related to the daily levels of SO2 air pollution and potential confounders (available from various sources) using log-linear regression analysis. Variables considered as potential confounders were: average temperature; difference between maximum and minimum temperatures; amount of precipitation; air humidity; wind speed; influenza incidence; and calendar year, month, and weekday. Both lagged and unlagged effects of the meteorological and influenza variables were considered. Average temperature was represented by two variables--cold, temperatures below 16.5 degrees C, and warm, those above 16.5 degrees C--to allow for the V shaped relation between temperature and mortality. The positive regression coefficient for the univariate effect of SO2 density on mortality from all causes dwindles to close to zero when all potential confounding variables are taken into account. The most important of these represents the lagged (one to five days) effect of low temperatures. Low temperatures have strong lagged effects on mortality, and often precede relatively high SO2 densities in the Netherlands. Results were similar for separate causes of death. While univariate associations suggest an effect of air pollution on mortality in all four cause of death groups, multivariate analyses show these effects, including that on mortality from respiratory diseases, are a result of confounding. CONCLUSIONS--The SO2 density (or that of compounds closely associated with SO2) does not seem to have any short term effect on mortality in the Netherlands. SO2 levels higher than those currently reached in the Netherlands (above 200 micrograms/m3) may have a measurable effect on mortality and this should be investigated. Furthermore, analyses of the public health impact of outdoor air pollution should properly control for the lagged effects of temperature.

Regional differences in mortality from conditions amenable to medical intervention in The Netherlands: a comparison of four time periods.

In The Netherlands, as in many other countries, important geographical variation in mortality from conditions amenable to medical intervention exists. Associations with a number of simple medical care supply characteristics (general practitioner density, hospital bed density, and percentage of regional hospital beds located in university and small hospitals) are generally weak and inconsistent, both before and after controlling for possible confounding factors. We explored one of the possible reasons for this lack of consistency, which is the time dependency of the relationship between medical care supply and avoidable mortality. A comparison of associations in four time periods (1950-54, 1960-64, 1970-74 and 1980-84) shows that the percentage of variance in regional mortality levels which can be explained by the medical care supply variables has changed over time. Although the patterns of change differ little from what one would expect on the basis of the time of introduction of medical care innovations, the exact nature of the associations is puzzling. Apart from some expected negative associations between mortality and the presence of university hospitals, we also found a few unexpected positive associations with general practitioner density. Possible explanations for these findings are discussed, and it is concluded that further study is necessary to reveal the causes of a higher or lower mortality level for conditions considered to be amenable to medical intervention.

Preventing socioeconomic inequalities in health behaviour in adolescents in Europe: background, design and methods of project TEENAGE.

BackgroundHigher prevalence rates of unhealthy behaviours among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health in adults. Preventing the development of these inequalities in unhealthy behaviours early in life is an important strategy to tackle socioeconomic inequalities in health. Little is known however, about health promotion strategies particularly effective in lower socioeconomic groups in youth. It is the purpose of project TEENAGE to improve knowledge on the prevention of socioeconomic inequalities in physical activity, diet, smoking and alcohol consumption among adolescents in Europe. This paper describes the background, design and methods to be used in the project.Methods/designThrough a systematic literature search, existing interventions aimed at promoting physical activity, a healthy diet, preventing the uptake of smoking or alcohol, and evaluated in the general adolescent population in Europe will be identified. Studies in which indicators of socioeconomic position are included will be reanalysed by socioeconomic position. Results of such stratified analyses will be summarised by type of behaviour, across behaviours by type of intervention (health education, environmental interventions and policies) and by setting (individual, household, school, and neighbourhood). In addition, the degree to which effective interventions can be transferred to other European countries will be assessed.DiscussionAlthough it is sometimes assumed that some health promotion strategies may be particularly effective in higher socioeconomic groups, thereby increasing socioeconomic inequalities in health-related behaviour, there is little knowledge about differential effects of health promotion across socioeconomic groups. Synthesizing stratified analyses of a number of interventions conducted in the general adolescent population may offer an efficient guidance for the development of strategies and interventions to prevent socioeconomic inequalities in health early in life.

Geographic variation in the onset of decline of male ischemic heart disease mortality in The Netherlands.

We studied variation in the year of onset of ischemic heart disease mortality decline among regions (n = 39) in the Netherlands. Using loglinear regression methods, a quadratic regression model was fitted to the observed numbers of male deaths in each region in the period 1950-84, controlling for changes in age-structure of populations. The quadratic regression model proved inadequate to describe the mortality experience of females. For the country as a whole, the estimated year of onset of male ischemic heart disease mortality decline is 1973.9. The difference between the earliest and the latest region is almost nine years (1970.0 and 1978.9, respectively). An early onset of decline (less than or equal to 1972) is only found in the urbanized, western part of the country. A later (greater than or equal to 1975) onset of decline is characteristically found in more peripheral regions in the South-West and South-East, as well as in the North. Exploratory correlation and regression analyses show that both average income and percent of population living in larger cities have independent, negative associations with the year of onset of male ischemic heart disease mortality decline. We argue that regional variation in the timing of lifestyle changes is a more plausible explanation of these observations than regional variation in the timing of medical care improvements.

Educational inequalities in tuberculosis mortality in sixteen European populations

OBJECTIVEnTo describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries.nnnDESIGNnData were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities.nnnRESULTSnThe number of TB deaths reported was 8530, with a death rate of 3 per 100 000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations.nnnCONCLUSIONSnSocio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

Gains in life expectancy by eliminating major causes of death: Revised estimates taking into account competing causes of death

Essential for the description of the health situation of a nation is an assessment of the contribution that different diseases make to the burden of illness, disability and premature death. Comparisons of diseases in terms of deaths have a long tradition, and have led to the development of a number of life-table based measures such as the potential gain in life expectancy by eliminating specific causes of death. These measures provide an easy-to-grasp and powerful summary of the relative importance of specific causes of death, as well as of the potential benefits of intervention programmes (Chiang, 1978; Preston et al., 1972, US Department of Health, 1988; Tsai et al., 1978; Keyfitz, 1977).