Charles R. Gillis

Impaired lung function and mortality risk in men and women : findings from the Renfrew and Paisley prospective population study

Abstract Objective: To assess the relation between forced expiratory volume in one second (FEV1) and subsequent mortality. Design: Prospective general population study. Setting: Renfrew and Paisley, Scotland. Subjects: 7058 men and 8353 women aged 45-64 years at baseline screening in 1972-6. Main outcome measure: Mortality from all causes, ischaemic heart disease, cancer, lung and other cancers, stroke, respiratory disease, and other causes of death after 15 years of follow up. Results: 2545 men and 1894 women died during the follow up period. Significant trends of increasing risk with diminishing FEV1 are apparent for both sexes for all the causes of death examined after adjustment for age, cigarette smoking, diastolic blood pressure, cholesterol concentration, body mass index, and social class. The relative hazard ratios for all cause mortality for subjects in the lowest fifth of the FEV1 distribution were 1.92 (95% confidence interval 1.68 to 2.20) for men and 1.89 (1.63 to 2.20) for women. Corresponding relative hazard ratios were 1.56 (1.26 to 1.92) and 1.88 (1.44 to 2.47) for ischaemic heart disease, 2.53 (1.69 to 3.79) and 4.37 (1.84 to 10.42) for lung cancer, and 1.66 (1.07 to 2.59) and 1.65 (1.09 to 2.49) for stroke. Reduced FEV1 was also associated with an increased risk for each cause of death examined except cancer for lifelong nonsmokers. Conclusions: Impaired lung function is a major clinical indicator of mortality risk in men and women for a wide range of diseases. The use of FEV1 as part of any health assessment of middle aged patients should be considered. Smokers with reduced FEV1 should form a priority group for targeted advice to stop smoking. Key messages These increased risks, with the exception of the cancers, are apparent for lifelong non-smokers FEV1 is second in importance to cigarette smoking as a predictor of subsequent all cause mortality and is as important as cholesterol in predicting mortality from ischaemic heart disease FEV1 should be included in health assessment of middle aged men and women Smokers with a reduced FEV1 should be targeted with advice to stop smoking

Education and occupational social class: which is the more important indicator of mortality risk?

STUDY OBJECTIVES: In the UK, studies of socioeconomic differentials in mortality have generally relied upon occupational social class as the index of socioeconomic position, while in the US, measures based upon education have been widely used. These two measures have different characteristics; for example, social class can change throughout adult life, while education is unlikely to alter after early adulthood. Therefore different interpretations can be given to the mortality differentials that are seen. The objective of this analysis is to demonstrate the profile of mortality differentials, and the factors underlying these differentials, which are associated with the two socioeconomic measures. DESIGN: Prospective observational study. SETTING: 27 work places in the west of Scotland. PARTICIPANTS: 5749 men aged 35-64 who completed questionnaires and were examined between 1970 and 1973. FINDINGS: At baseline, similar gradients between socioeconomic position and blood pressure, height, lung function, and smoking behaviour were seen, regardless of whether the education or social class measure was used. Manual social class and early termination of full time education were associated with higher blood pressure, shorter height, poorer lung function, and a higher prevalence of smoking. Within education strata, the graded association between smoking and social class remains strong, whereas within social class groups the relation between education and smoking is attenuated. Over 21 years of follow up, 1639 of the men died. Mortality from all causes and from three broad cause of death groups (cardiovascular disease, malignant disease, and other causes) showed similar associations with social class and education. For all cause of death groups, men in manual social classes and men who terminated full time education at an early age had higher death rates. Cardiovascular disease was the cause of death group most strongly associated with education, while the non-cardiovascular non-cancer category was the cause of death group most strongly associated with adulthood social class. The graded association between social class and all cause mortality remains strong and significant within education strata, whereas within social class strata the relation between education and mortality is less clear. CONCLUSIONS: As a single indicator of socioeconomic position occupational social class in adulthood is a better discriminator of socioeconomic differentials in mortality and smoking behaviour than is education. This argues against interpretations that see cultural--rather than material--resources as being the key determinants of socioeconomic differentials in health. The stronger association of education with death from cardiovascular causes than with other causes of death may reflect the function of education as an index of socioeconomic circumstances in early life, which appear to have a particular influence on the risk of cardiovascular disease.

Intergenerational 20 year trends in the prevalence of asthma and hay fever in adults: the Midspan family study surveys of parents and offspring.

Abstract Objective: To estimate trends between 1972–6 and 1996 in the prevalences of asthma and hay fever in adults. Design: Two epidemiological surveys 20 years apart. Identical questions were asked about asthma, hay fever, and respiratory symptoms at each survey. Setting: Renfrew and Paisley, two towns in the west of Scotland. Subjects: 1477 married couples aged 45–64 participated in a general population survey in 1972-6; and 2338 offspring aged 30–59 participated in a 1996 survey. Prevalences were compared in 1708 parents and 1124 offspring aged 45-54. Main outcome measures: Prevalences of asthma, hay fever, and respiratory symptoms. Results: In never smokers, age and sex standardised prevalences of asthma and hay fever were 3.0% and 5.8% respectively in 1972-6, and 8.2% and 19.9% in 1996. In ever smokers, the corresponding values were 1.6% and 5.4% in 1972–6 and 5.3% and 15.5% in 1996. In both generations, the prevalence of asthma was higher in those who reported hay fever (atopic asthma). In never smokers, reports of wheeze not labelled as asthma were about 10 times more common in 1972–6 than in 1996. With a broader definition of asthma (asthma and/or wheeze), to minimise diagnostic bias, the overall prevalence of asthma changed little. However, diagnostic bias mainly affected non-atopic asthma. Atopic asthma increased more than twofold (prevalence ratio 2.52 (95% confidence interval 1.01 to 6.28)) whereas the prevalence of non-atopic asthma did not change (1.00 (0.53 to 1.90)). Conclusion: The prevalence of asthma in adults has increased more than twofold in 20 years, largely in association with trends in atopy, as measured indirectly by the prevalence of hay fever. No evidence was found for an increase in diagnostic awareness being responsible for the trend in atopic asthma, but increased awareness may account for trends in non-atopic asthma.

Cardiorespiratory Disease in Men and Women in Urban Scotland: Baseline Characteristics of the Renfrew/Paisley(Midspan) Study Population

Study objective: To describe the distribution of risk factors, risk behaviours, symptoms and the prevalence of cardiorespiratory disease in men and women in an urban area with high levels of socioeconomic deprivation. A cross-sectional survey of 15,411 men and women aged 45–64, comprising an 80% response rate from the general population in Paisley and Renfrew, Scotland Main results: The main characteristics of the male Renfrew/Paisley population, compared to previous British studies, were shorter stature, higher blood pressure, a higher proportion of smokers who continue to smoke, lower FEV1 and higher levels of reported angina, breathlessness on effort and chronic bronchitis. In comparison with men, the main characteristics of the female Renfrew/Paisley population were shorter stature, higher plasma cholesterol, lower FEV1′ fewer current and ex-smokers, and a higher prevalence of breathlessness on effort. There were only small differences between men and women in the prevalence of angina, ECG evidence of myocardial ischaemia and chronic bronchitis. Conclusions: Middle-aged men and women in an urban area with high levels of socio-economic deprivation have different cardio- respiratory risk and disease profiles compared to previous population studies in the UK, based on occupational groups and random national samples.

The waiting time paradox: population based retrospective study of treatment delay and survival of women with endometrial cancer in Scotland

Delay in the delivery of treatment for gynaecological cancers has been previously investigated.1 2 In some cases, thedelay reflects the illness behaviour of women; in others, it was inherent in the system for delivering health care. Few studies have linked delay in treatment with survival, although a study from Israel found that survival from endometrial cancer was not affected by a delay in treatment of four months.3 We investigated links between delays in treatment and survival, using a recently completed audit of endometrial cancer treatment in Scotland. We collected data from the case notes of all women resident in Scotland who were diagnosed between 1 January 1996 and 31 December 1997 as having …

Socio-economic deprivation and stage of disease at presentation in women with breast cancer

BACKGROUND This study describes and compares the pathological prognostic factors and surgeon assessment of stage of breast cancer of women living in affluent and deprived areas to assess whether clinical stage at presentation may explain the known poorer survival outcomes for deprived women. PATIENTS AND METHODS A population-based review of the case records of 417 women with breast cancer was carried out. RESULTS No difference in pathological criteria was found between the 88% of women living in affluent and deprived areas for whom such data were available. Clinical assessment of the remaining 50 cases showed that women living in deprived areas were more likely to present with locally advanced or metastatic disease. CONCLUSION The poorer survival of women from deprived areas with breast cancer may be explained by more deprived women presenting with advanced cancers.

Psychological distress, physical illness and mortality risk

BACKGROUND Psychological distress has been associated with an increased risk of overall and disease-specific mortality risk. This study examines whether the length of follow-up time influences mortality risk. METHODS The associations between psychological distress and all-cause and coronary heart disease mortality were modelled using proportional hazards modelling in a prospective cohort study of 6920 men and women aged 45-64 years. Psychological distress was assessed at baseline using the 30-item General Health Questionnaire (GHQ-30). RESULTS Psychological distress was associated with a 5-year all-cause mortality (RR 1.68 95% CI 1.07-2.62) and CHD mortality (RR 1.64 95% CI 1.02-2.56) in men after adjustment for sociodemographic and CHD risk factors, but not after further adjustment for baseline physical illness (RR 1.41 95% CI 0.88-2.23) for all-cause mortality (RR 1.39 95% CI 0.88-2.21) for CHD mortality. Psychological distress was not associated with all-cause and CHD mortality at 15- and 20-year follow-up. CONCLUSIONS Psychological distress is a reflection of baseline physical illness that increases mortality risk. Psychological distress maybe on the causal pathway between physical illness and mortality risk.

Sociodemographic factors, smoking and common mental disorder in the Renfrew and Paisley (MIDSPAN) study

The relationships between common mental disorder measured by the General Health Questionnaire and sociodemographic variables and cigarette smoking were examined from baseline data in a community study of 15,406 men and women, aged between 45 and 64 years from two towns close to Glasgow. Between 1972 and 1976 all those respondents from Renfrew and Paisley between the ages of 45 and 64 years who met the residency criteria were invited to attend community clinics, where a clinical examination was carried out and the General Health Questionnaire was completed by 3783 (53.6 percent) men, and 4683 (56.1 percent) women. Women had a higher risk of disorder than men did. More women (20.3 percent) than men (15.4 percent) were possible cases of common mental disorder. Women showed a decrease in disorder with age but no apparent trend in men was observed. Marital status was significantly associated with disorder, with the widowed and separated showing especially high rates of psychiatric disorder. Married men, in contrast to married women, had relatively low levels of psychiatric disorder. Both social class and level of deprivation of the area were associated with psychiatric disorder. For both men and women there was a trend in disorder associated with social class; men in social class V had twice the level of psychiatric disorder compared to those in social class II. For women there was a shallow gradient showing higher levels of disorder with lower social class. Smoking habits were also related to psychiatric disorder; never- and exsmokers had relatively low rates of psychiatric disorder whereas, among current smokers, risk of psychiatric disorder, increased with the number of cigarettes smoked, though only for women.

Social mobility, health, and cardiovascular mortality

R S BHOPAL (Department of Epidemiology and Public Health, University of Newcastle upon Tyne) Introduction The description ofhuman characteristics, including health, by racial group has beguiled researchers in many disciplines, including epidemiology. Some careers have been ruined in hindsight by racist, prejudiced, or simply misguided work in this highly complex and controversial arena of research. With the concept of race under attack, ethnicity has now occupied the vacated ground. Ethnicity has become a key, almost routine, epidemiological variable and there is strong pressure on researchers to collect information on it. There have been repeated and enthusiastic claims, by researchers, policy makers, and health planners, about the value of ethnicity and health research. This paper presents a critical analysis of the past and potential value of ethnicity, race, and health research based on epidemiological methods. The key questions are whether such research can inform our understanding of disease causation or help develop appropriate health services (enlightenment), add to our collection of unexplained associations (blackbox epidemiology), or is merely information of little value (junk). Approach to the paper A historical analysis will subject the claims of race and health researchers in the past to the reality of today. In addition, hypotheses will be extracted from the epidemiological literature of the 1970s and 1980s. The number of hypotheses which have been pursued and either rejected or supported by subsequent work will be the critical factor in assessing the value of ethnicity and health research in understanding disease causation. Furthermore, the quality of the research that has been done and is underway will be explored in relation to the definition of terms, validity of measurement of ethnicity, quality control of data collection, and the statement of hypotheses which permits their testing. The extent to which studies done in the late 1970s and early 1980s have been used to create appropriate health policy and health plans will be reviewed. Results of the analysis to date The work for this paper is not complete but the preliminary findings are that claims of race, ethnicity, and health researchers are highly exaggerated and that information from these studies is hard to utilise for aetiological or service applications. There are grave problems with the way researchers have collected and presented information on ethnicity and health, and with the validity of data collection used in cross cultural studies. The health services have found it difficult to respond to meet the needs of ethnic minority groups and it is unclear whether research has helped or hindered. From a historical point of view it will be argued that race research has done more harm than good, with many studies breaching research ethics and principles. It is highly pertinent to examine whether ethnicity and health research may also be breaching such principles. This analysis will argue for a deeper analysis of the value of ethnicity and health research in epidemiology so that its strengths and limitations can be more widely understood; exaggerated claims are not made; and expectations of researchers, policy makers, and ethnic minorities are maintained at realistic levels.

Common mental disorder and physical illness in the Renfrew and Paisley (MIDSPAN) study

OBJECTIVE AND METHODS The relationship between psychological distress measured by the General Health Questionnaire 30 (GHQ-30) and risk factors for coronary heart disease, angina, electrocardiogram (ECG) abnormalities and chronic sputum was modelled using logistic regression on baseline data from a community study of 15,406 men and women. RESULTS Psychological distress was associated with low forced expiratory volume (FEV(1)) and low body mass index (BMI) in men, and low systolic blood pressure only in women. There were associations between psychological distress and coronary heart disease and cardiorespiratory outcomes. The associations were particularly strong for angina without ECG abnormalities (Men: OR 3.26, 95% CI 2.52-4.21; Women: OR 2.89, 95% CI 2.35-3.55) and for angina with ECG abnormalities (Men: OR 2.68, 95% CI 2.03-4.52; Women: OR 2.88, 95% CI 1.89-4.39), in both men and women, even after adjusting for classical CHD and cardiorespiratory risk factors. An association between psychological distress and severe chest pain, indicative of previous myocardial infarction, was found in both men and women (Men: OR 1.89, 95% CI 1.44-2.47; Women: OR 1.91, 95% CI 1.48-2.47), respectively, and between psychological distress and ECG ischaemia, but in men only (OR 1.32, 95% CI 1.00-1.76). CONCLUSION The association between psychological distress and cardiorespiratory outcomes is likely to be a consequence of the pain and discomfort of the symptoms of the illness. Chest pain may also be a symptom of psychological distress. However, psychological distress, as a predictor and possible risk factor increasing the risk of coronary heart disease, cannot be ruled out.