Uwe Helmert

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.

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education

Objective: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. Design: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. Setting: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. Participants: 451 386 non-institutionalised men and women 25–79 years old. Main outcome measures: Smoking status, daily quantity of cigarettes consumed by smokers. Results: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. Conclusions: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.

Differences in self reported morbidity by educational level: a comparison of 11 western European countries.

STUDY OBJECTIVE: To assess whether there are variations between 11 Western European countries with respect to the size of differences in self reported morbidity between people with high and low educational levels. DESIGN AND METHODS: National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable effort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity differences was measured by means of the regression based Relative Index of Inequality. MAIN RESULTS: The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator. CONCLUSIONS: Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.

Persistent variations in average height between countries and between socio-economic groups: an overview of 10 European countries.

Primary objectives: This paper aims to provide an overview of variations in average height between 10 European countries, and between socio-economic groups within these countries. Data and methods: Data on self-reported height of men and women aged 20-74 years were obtained from national health, level of living or multipurpose surveys for 1987-1994. Regression analyses were used to estimate height differences between educational groups and to evaluate whether the differences in average height between countries and between educational groups were smaller among younger than among older birth cohorts. Results: Men and women were on average tallest in Norway, Sweden, Denmark and the Netherlands and shortest in France, Italy and Spain (range for men: 170-179 cm; range for women: 160-167 cm). The differences in average height between northern and southern European countries were not smaller among younger than among older birth cohorts. In most countries average height increased linearly with increasing birth-year (≈0.7-0.8cm/5 years for men and ≈0.4cm/5 years for women). In all countries, lower educated men and women on average were shorter than higher educated men (range of differences: 1.6-3.0 cm) and women (range of differences: 1.2-2.2 cm). In most countries, education-related height differences were not smaller among younger than among older birth cohorts. Conclusions: The persistence of international differences in average height into the youngest birth cohorts indicates a high degree of continuity of differences between countries in childhood living conditions. Similarly, the persistence of education-related height differences indicates continuity of socio-economic differences in childhood living conditions, and also suggests that socio-economic differences in childhood living conditions will continue to contribute to socio-economic differences in health at adult ages.

Comparative appraisal of educational inequalities in overweight and obesity among adults in 19 European countries

BACKGROUND In Western societies, a lower educational level is often associated with a higher prevalence of overweight and obesity. However, there may be important international differences in the strength and direction of this relationship, perhaps in respect of differing levels of socio-economic development. We aimed to describe educational inequalities in overweight and obesity across Europe, and to explore the contribution of level of socio-economic development to cross-national differences in educational inequalities in overweight and obese adults in Europe. METHODS Cross-sectional data, based on self-reports, were derived from national health interview surveys from 19 European countries (N = 127 018; age range = 25-44 years). Height and weight data were used to calculate the body mass index (BMI). Multivariate regression analysis was employed to measure educational inequalities in overweight and obesity, based on BMI. Gross domestic product (GDP) per capita was used as a measure of level of socio-economic development. RESULTS Inverse educational gradients in overweight and obesity (i.e. higher education, less overweight and obesity) are a generalized phenomenon among European men and even more so among women. Baltic and eastern European men were the exceptions, with weak positive associations between education and overweight and obesity. Educational inequalities in overweight and obesity were largest in Mediterranean women. A 10 000-euro increase in GDP was related to a 3% increase in overweight and obesity for low-educated men, but a 4% decrease for high-educated men. No associations with GDP were observed for women. CONCLUSION In most European countries, people of lower educational attainment are now most likely to be overweight or obese. An increasing level of socio-economic development was associated with an emergence of inequalities among men, and a persistence of these inequalities among women.

Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries

Background: Recently a scale was introduced to quantify the implementation of tobacco control policies at country level. Our study used this scale to examine the potential impact of these policies on quit ratios in European countries. Special attention was given to smoking cessation among lower educational groups. Methods: Cross-sectional data were derived from national health surveys from 18 European countries. In the analyses we distinguished between country, sex, two age groups (25–39 and 40–59 years) and educational level. Age-standardised quit ratios were calculated as total former-smokers divided by total ever-smokers. In regression analyses we explored the correlation between national quit ratios and the national score on the Tobacco Control Scale (TCS). Results: Quit ratios were especially high (>45%) in Sweden, England, The Netherlands, Belgium and France and relatively low (<30%) in Lithuania and Latvia. Higher educated smokers were more likely to have quit smoking than lower educated smokers in all age-sex groups in all countries. National score on the tobacco control scale was positively associated with quit ratios in all age-sex groups. The association of quit ratios with score on TCS did not show consistent differences between high and low education. Of all tobacco control policies of which the TCS is constructed, price policies showed the strongest association with quit ratios, followed by an advertising ban. Conclusion: Countries with more developed tobacco control policies have higher quit ratios than countries with less developed tobacco control policies. High and low educated smokers benefit about equally from the nationwide tobacco control policies.

Regular Analgesic Intake and the Risk of End-Stage Renal Failure

The strength of the association between regular analgesic intake (RAI) and end-stage renal failure (EF) has been insufficiently established until now. A case-control study was conducted to estimate the relative risks (RR) of EF after RAI (defined as consumption of 15 or more analgesic doses per month for a continuous period of at least 1 year) for cumulative drug intake, single-ingredient analgesics, combinations, and specific compounds. The case group included all patients with EF undergoing renal replacement therapy in the area of West Berlin (1984-1986, n = 921). Control subjects, matched to cases by sex, age, and nationality, were selected from a group of patients in outpatient clinics. Matching was possible for 517 cases. The RR of EF after RAI of any analgesic was 2.44 (95% confidence interval: 1.77-3.39) and after RAI of combination drugs 2.65 (95% confidence interval 1.91-3.67). No significant increase was found, however, after RAI of single-ingredient analgesics. The RR after RAI of combination drugs and for the most preferred analgesic ingredients (phenacetin, paracetamol, acetylsalicylic acid, phenazones, caffeine) increased with dose. Furthermore, a dose-time-related RR after RAI of the longest used preparation was found. Thus, the results clearly show an increased RR of EF after RAI related to both dose and exposure time of mixed analgesic compounds, but not for the use of only single-ingredient analgesics.

Female ever-smoking, education, emancipation and economic development in 19 European countries

Large differences in ever-smoking rates among women are found between countries and socio-economic groups. This study examined the socio-economic inequalities in female ever-smoking rates in 19 European countries, and explored the association between cross-national differences in these inequalities and economic development and womens emancipation. Data on smoking were derived from national health interview surveys from 19 European countries. For each country, age group (25-39, 40-59 and 60+ years), educational level (4 standard levels), and cumulative ever-smoking rates were calculated as the proportion of current and former smokers of the total survey population. A Relative Index of Inequality was estimated for women in the three age groups to measure the magnitude of educational differences. In regression analyses the association of ever-smoking rates of women age 25-39 years with the gross domestic product (GDP) and the Gender Empowerment Measure (GEM) was explored. Less educated women aged 25-39 years were more likely to have ever smoked than more educated women in all countries, except Portugal. In the age groups 40-59 years the educational pattern differed between countries. Women aged 60+ years who were less educated were less likely to have ever smoked in all countries, except Norway and England. The size of inequalities varied considerably between countries and reversed within three age groups. For women 25-39 years, the association of ever-smoking rates with GDP was positive, especially for more educated women. The association of ever-smoking rates with GEM was positive for less educated women, but negative for more educated women. The results are consistent with the idea that economic development and social-cultural processes related to gender empowerment have affected the diffusion of smoking in different ways for more and less educated women.

Social inequities in cardiovascular disease risk factors in east and West Germany

Social class related differences in prevalence of cardiovascular disease risk factors in Germany were investigated with special emphasis on comparisons between East and West Germany and on time trends. Databases for West Germany are the first and second National Health Survey (survey 1: N = 4794, survey 2: N = 5315), carried out in the framework of the German Cardiovascular Prevention Study, and for East Germany the first GDR-MONICA project (N = 6125). Different social class indices were applied to evaluate social inequities for hypertension, hypercholesterolemia, cigarette smoking, obesity and predicted cardiovascular disease mortality. As a main result, it was found that very similar patterns in the relation between social class characteristics and cardiovascular disease risk factor prevalence occurred for both parts of Germany. Social class gradients were strongest for obesity and weakest for hypercholesterolemia. Analysis of time trends for the period from 1984 to 1988 (for West Germany only) revealed an increase in social inequalities for hypertension in males and cigarette smoking in females. These findings point to the need to focus more on social disadvantaged segments in the population when community based health promotion and disease prevention programs are brought into action.

Association between educational level and vegetable use in nine European countries

OBJECTIVE The relationship of socio-economic status and vegetable consumption is examined in nine European countries. The aim is to analyse whether the pattern of socio-economic variation with regard to vegetable consumption is similar in all studied countries with high v. low vegetable availability and affordability, and whether education has an independent effect on vegetable consumption once the effects of other socio-economic factors have been taken into account. DESIGN The data for the study were obtained from national surveys conducted in Finland, Denmark, Germany, Estonia, Latvia, Lithuania, France, Italy and Spain, in 1998 or later. These surveys included data on the frequency of use of vegetables. Food Balance Sheets indicated that the availability of vegetables was best in the Mediterranean countries. The prices of vegetables were lowest in the Mediterranean countries and Germany. RESULTS Educational level was positively associated with vegetable consumption in the Nordic and Baltic countries. In the Mediterranean countries, education was not directly associated with the use of vegetables but, after adjusting for place of residence and occupation, it was found that those with a lower educational level consumed vegetables slightly more often. Manual workers consumed vegetables less often than non-manual workers, but otherwise there was no systematic association with occupation. CONCLUSIONS The Mediterranean countries did not show a positive association between educational level and vegetable consumption. The positive association found in the Northern European countries is linked to the lower availability and affordability of vegetables there and their everyday cooking habits with no long-standing cultural tradition of using vegetables.