Determinants of inequalities in life expectancy: an international comparative study of eight risk factors

Interrupted time series analyses to assess the impact of alcohol control policy on socioeconomic inequalities in mortality in Lithuania: a study protocol

INTRODUCTION

Alcohol use is a major risk factor for mortality. Previous studies suggest that the alcohol-attributable mortality burden is higher in lower socioeconomic strata. This project will test the hypothesis that the 2017 increase of alcohol excise taxes linked to lower all-cause mortality rates in previous analyses will reduce socioeconomic mortality inequalities.

METHODS AND ANALYSIS

Data on all causes of deaths will be obtained from Statistics Lithuania. Record linkage will be implemented using personal identifiers combining data from (1) the 2011 whole-population census, (2) death records between 1 March 2011 (census date) and 31 December 2019, and (3) emigration records, for individuals aged 40-70 years. The analyses will be performed separately for all-cause and for alcohol-attributable deaths. Monthly age-standardised mortality rates will be calculated by sex, education and three measures of socioeconomic status (SES). Inequalities in mortality will be assessed using absolute and relative indicators between low and high SES groups. We will perform interrupted time series analyses, and test the impact of the 2017 rise in alcohol excise taxation using generalised additive mixed models. In these models, we will control for secular trends for economic development.

ETHICS AND DISSEMINATION

This work is part of project grant 1R01AA028224-01 by the National Institute on Alcohol Abuse and Alcoholism. It has been granted research ethics approval 050/2020 by Centre for Addiction and Mental Health Research Ethics Board on 17 April 2020, renewed on 30 March 2021. The time series of mortality inequalities as well as the statistical code will be made publicly available, allowing other researchers to adapt the proposed method to other jurisdictions.

Participation in recreational activities varies with socioeconomic position and is associated with self-rated health and well-being

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This study shows social inequalitues in recreational activity participation (RAP).

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Regardless of educational level, RAP was associated with better self-rated health.

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RAP may modify social inequality in self-rated health and quality of life.

Recreational activities may promote and maintain health and well-being, but empirical evidence is limited. The aim of this study was to explore socioeconomic variations in participation in recreational activities in the local community and to examine associations with health and well-being in the general population.

Participants ≥ 16 years from the Danish Capital Region Health Survey, conducted in 2017 (N = 55,185, response rate 52.6%) were included. Participation in community-based recreational activities, self-rated health, quality of life, and health status was assessed by questionnaire. Socioeconomic variables (educational level, occupational and marital status) were obtained from national registers. Multiple logistic regression models were used to examine associations.

Less than half of the population participated in community-based recreational activities. Individuals with a higher educational level were 55% more likely to participate in recreational activities compared to those with a lower educational level (OR = 1.55, CI:1.45–1.66). Individuals with a low educational level who participated in recreational activities, were more likely to have an excellent/good quality of life (OR = 2.03 (95% CI:1.86–2.21)) and an excellent/very good self-rated health (OR = 1.61 (95% CI:1.51–1.71)), than those who did not participate in recreational activities.

Regardless of educational level, recreational activity participation was associated with better self-rated health and quality of life. Thus, to counter-balance social inequality in health, a focus on participation in recreational activities is important when planning community public health interventions.

The impact of an unequal distribution of education on inequalities in life expectancy

Prior research has found socio-economic determinants such as education to affect health outcomes. Yet, education is not distributed equally among the population. This article attempts to quantify the impact of unequal distribution of education on inequalities in life expectancy. We calculate a Gini coefficient of longevity from the life tables provided by the Human Mortality Database and a Gini coefficient of education using data on educational attainment from Barro and Lee (2013). We estimate linear regression models to examine the relationship between inequality in education and inequality in life expectancy at the country level for up to 31 European countries between 1970 and 2010. Results provide empirical evidence for a statistically significant positive association between educational inequality and inequalities of longevity. Confounding factors reflecting individual health behaviour such as cigarette or alcohol consumption do not exert a separate statistically significant effect on inequality in life expectancy. Findings are robust to alternative calculation of key variables, dropping a potential outlier, and an alternative estimation approach. These findings suggest that not only education, but also equality in education is a crucial factor for health outcomes. Continuing efforts should be directed towards the reduction of educational inequality in order to reduce inequality in longevity within a country.

The dose-response relationship between socioeconomic deprivation and alcohol-attributable mortality risk-a systematic review and meta-analysis

BACKGROUND

Individuals with low socioeconomic status (SES) experience a higher risk of mortality, in general, and alcohol-attributable mortality in particular. However, a knowledge gap exists concerning the dose-response relationships between the level of socioeconomic deprivation and the alcohol-attributable mortality risk.

METHODS

We conducted a systematic literature search in August of 2020 to update a previous systematic review that included studies published up until February of 2013. Quantitative studies reporting on socioeconomic inequality in alcohol-attributable mortality among the general adult population were included. We used random-effects dose-response meta-analyses to investigate the relationship between the level of socioeconomic deprivation and the relative alcohol-attributable risk (RR), by sex and indicator of SES (education, income, and occupation).

RESULTS

We identified 25 eligible studies, comprising about 241 million women and 230 million men, among whom there were about 75,200 and 308,400 alcohol-attributable deaths, respectively. A dose-response relationship between the level of socioeconomic deprivation and the RR was found for all indicators of SES. The sharpest and non-linear increase in the RR of dying from an alcohol-attributable cause of death with increasing levels of socioeconomic deprivation was observed for education, where, compared to the most educated individuals, individuals at percentiles with decreasing education had the following RR of dying: women: 25th: 2.09 [95% CI 1.70-2.59], 50th: 3.43 [2.67-4.49], 75th: 4.43 [3.62-5.50], 100th: 4.50 [3.26-6.40]; men: 25th: 2.34 [1.98-2.76], 50th: 4.22 [3.38-5.24], 75th: 5.87 [4.75-7.10], 100th: 6.28 [4.89-8.07].

CONCLUSIONS

The findings of this study show that individuals along the entire continuum of SES are exposed to increased alcohol-attributable mortality risk. Differences in the dose-response relationship can guide priorities in targeting public health initiatives.

Socioeconomic Inequalities in Mortality After Age 67: The Contribution of Psychological Factors

Diverging trends of longer lives and increased inequalities in age-at-death invite to updated research on late-life mortality. Earlier studies have identified health behavior, childhood, psychosocial, and material conditions as key determinants of life expectancy, but the role of psychological factors remains a topic of debate. The current study is framed in a life course developmental perspective and assesses the mediating role of secondary control strategies (subjective age) and primary control capacity (perceived control) to socioeconomic (wealth and education) inequality in mortality after age 67. Data are derived from the second wave of the Norwegian Life Course, Ageing and Generation study (N=1,432 and age 67–85). All in all, 366 deaths were observed over a mean follow-up of 9.6years. Perceived control was measured by the Pearlin and Schooler Mastery Scale. SA was measured with proportional discrepancy scores in felt age and ideal age. Stepwise Cox proportional hazards regression analyses were conducted to analyze the relative contribution of SES (education and accumulated wealth), felt age, and ideal age discrepancies and perceived control on 11-year mortality. Findings show that lower levels of wealth and perceived control independently predict increased elderly mortality over an 11-year period. Feeling younger and smaller ideal age discrepancies are positively associated with perceived control, but do not account for additional variability in longevity among older adults. Findings add to the interdisciplinary field of socioeconomic inequalities in elderly mortality and underline the specific importance of structural conditions (wealth) and the continued importance of (perceived) primary control capacity for longevity also after age 67. Future research may assess in more detail how wealth and perceived control complement each other in contributing to healthy aging and longevity, for example, by longitudinal research including the role of significant life events in the second half of life in different welfare state contexts.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE

Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined.

DATA SOURCES

We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations.

DATA SYNTHESIS

Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition.

CONCLUSION

To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.

Determinants of inequalities in years with disability: an international-comparative study

Background

Persons with a lower socioeconomic position spend more years with disability, despite their shorter life expectancy, but it is unknown what the important determinants are. This study aimed to quantify the contribution to educational inequalities in years with disability of eight risk factors: father’s manual occupation, low income, few social contacts, smoking, high alcohol consumption, high body-weight, low physical exercise and low fruit and vegetable consumption.

Methods

We collected register-based mortality and survey-based disability and risk factor data from 15 European countries covering the period 2010–14 for most countries. We calculated years with disability between the ages of 35 and 80 by education and gender using the Sullivan method, and determined the hypothetical effect of changing the prevalence of each risk factor to the prevalence observed among high educated (‘upward levelling scenario’), using Population Attributable Fractions.

Results

Years with disability among low educated were higher than among high educated, with a difference of 4.9 years among men and 5.5 years among women for all countries combined. Most risk factors were more prevalent among low educated. We found the largest contributions to inequalities in years with disability for low income (men: 1.0 year; women: 1.4 year), high body-weight (men: 0.6 year; women: 1.2 year) and father’s manual occupation (men: 0.7 year; women: 0.9 year), but contributions differed by country. The contribution of smoking was relatively small.

Conclusions

Disadvantages in material circumstances (low income), circumstances during childhood (father’s manual occupation) and high body-weight contribute to inequalities in years with disability.

Explaining socioeconomic disparities in health behaviours: A review of biopsychological pathways involving stress and inflammation

The purpose of this article was to explore how individuals' position in a socioeconomic hierarchy is related to health behaviours that are related to socioeconomic disparities in health. We identified research which shows that: (a) low socioeconomic status (SES) is associated with living in harsh environments, (b) harsh environments are related to increased levels of stress and inflammation, (c) stress and inflammation impact neural systems involved in self-control by sensitising the impulsive system and desensitising the reflective system, (d) the effects are inflated valuations of small immediate rewards and deflated valuations of larger delayed rewards, (e) these effects are observed as increased delay discounting, and (f) delay discounting is positively associated with practicing more unhealthy behaviours. The results are discussed within an adaptive evolutionary framework which lays out how the stress response system, and its interaction with the immune system and brain systems for decision-making and behaviours, provides the biopsychological mechanisms and regulatory shifts that make widespread conditional adaptability possible. Consequences for policy work, interventions, and future research are discussed.

It's Sunny, Be Healthy? An International Comparison of the Influence of Sun Exposure and Latitude Lines on Self-Rated Health

The positive impact of sunshine on self-rated health is well known. For the first time, the relationship between sunshine and self-rated health is examined in the context of latitude lines in international comparison. The further people live from the equator, the lower sun exposure (UVB exposure) and the more often they experience a vitamin D deficiency. UVB exposure decreases with degrees of latitudinal lines, and in addition to that, sunshine duration is shorter in northern countries. In order to consider the connection, sunshine duration and degree of latitude lines were manually enriched from the German Meteorological Service (Deutscher Wetterdienst) to the International Social Survey Programs (2011): Health and Health Care and analyzed with a logistic multilevel model, as well as the inclusion of sunshine duration as a mediator. If sunshine hours, as well as latitude lines, are considered separately in models, both show a statistically significant effect. Together in one model, the sunshine hours lose their relationship and additionally there is no mediation. This suggests that the location of the region is the decisive component when considering self-rated health. Furthermore, an interaction between age and sunshine hours as well as latitude lines is also shown.

Inequalities in Life Expectancy by Education and Its Changes in Lithuania during 2001-2014

Background and Objectives: Reduction of health inequalities is a highly important task in public health policies worldwide. In Lithuania, inequalities in life expectancy (LE) by education level are among the greatest, compared to other European countries. However, studies on inequalities in LE by level of education over a long-term period are quite scarce in Lithuania. The aim of the study was to analyze inequalities in life expectancy by education and its changes in Lithuania during 2001-2014. Materials and Methods: Information on deaths (in population aged ≥30 years) was obtained from Statistics Lithuania. Life expectancy at age 30 (LE30) and 95% confidence intervals (CIs) were calculated using life tables. Inequalities in LE30 were assessed using rate differences. Joinpoint regression analysis was used to assess the trends and inequalities of LE30 during 2001-2014. Results: During 2001-2014, LE30 in males and females with post-secondary education was higher than in those with up-to-secondary education (p < 0.05). Among males and females, LE30 increased in both education groups, except for males with up-to-secondary education. Among individuals with post-secondary education, LE30 started increasing earlier and more quickly than in those with up-to-secondary education. Over the analyzed period, greater differences in LE30 between post-secondary and up-to-secondary education groups were found among males. Differences in LE30 due to different educational background were statistically significantly, increasing across the sexes with a more rapid increase for females than for males. During 2001 and 2014, the highest number of years of LE30 lost in both education groups was due to cardiovascular diseases. Conclusions: Throughout the period of 2001-2014, life expectancy in Lithuania in the post-secondary education group was statistically significantly longer and was increasing more rapidly compared to the up-to secondary education group. Inequalities in life expectancy by level of education significantly increased among both males and females.

Nordic welfare states-still standing or changed by the COVID-19 crisis?

Nordic welfare states are known for their universalistic and all-encompassing approach to welfare and having a long tradition for active labour market policy as tool in economic crises with adverse impact on employment. They have had a long tradition for strong egalitarian approaches and their residents are consistently among the happiest in the world. A key issue is whether a crisis like the COVID-19 outbreak is changing the Nordic welfare states. This article focuses on providing a description of what instruments the Nordic countries have taken or expect to use as part of dealing with the welfare challenges resulting from rising unemployment and greater social and economic insecurity in the wake of the crisis. The tentative conclusion is that the crisis so far has strengthened key characteristics of the Nordic welfare states by the state taking on a strong central role not only for the functioning of the market but also continued in a path-dependent way with universal and relatively generous benefits such as for those who become unemployed or have reduced income because of the crisis.

Socio-Economic Position, Cancer Incidence and Stage at Diagnosis: A Nationwide Cohort Study in Belgium

Background: Socio-economic position is associated with cancer incidence, but the direction and magnitude of this relationship differs across cancer types, geographical regions, and socio-economic parameters. In this nationwide cohort study, we evaluated the association between different individual-level socio-economic and -demographic factors, cancer incidence, and stage at diagnosis in Belgium. Methods: The 2001 census was linked to the nationwide Belgian Cancer Registry for cancer diagnoses between 2004 and 2013. Socio-economic parameters included education level, household composition, and housing conditions. Incidence rate ratios were assessed through Poisson regression models. Stage-specific analyses were conducted through logistic regression models. Results: Deprived groups showed higher risks for lung cancer and head and neck cancers, whereas an inverse relation was observed for malignant melanoma and female breast cancer. Typically, associations were more pronounced in men than in women. A lower socio-economic position was associated with reduced chances of being diagnosed with known or early stage at diagnosis; the strongest disparities were found for male lung cancer and female breast cancer. Conclusions: This study identified population groups at increased risk of cancer and unknown or advanced stage at diagnosis in Belgium. Further investigation is needed to build a comprehensive picture of socio-economic inequality in cancer incidence.

Determinants of educational inequalities in disability-free life expectancy between ages 35 and 80 in Europe

Socioeconomic inequalities in disability-free life expectancy (DFLE) exist across all European countries, yet the driving determinants of these differences are not completely known. We calculated the impact on educational inequalities in DFLE of equalizing the distribution of eight risk factors for mortality and disability using register-based mortality data and survey data from 15 European countries for individuals between 35 and 80 years old. From the selected risk factors, the ones that contribute the most to the educational inequalities in DFLE are low income, high body-weight, smoking (for men), and manual occupation of the father. Potentially large reductions in inequalities can be achieved in Eastern European countries, where educational inequalities in DFLE are also the largest.

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Disability-free life expectancy is lower among low than the high educated in Europe.

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Over-all, the risk factor contributing most to the inequality was low income.

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Other important contributors are high body-weight, smoking and father's manual occupation.

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Size of inequality and contribution of risk factors vary importantly between countries.

Tailoring interventions for social isolation among older persons during the COVID-19 pandemic: challenges and pathways to healthcare equity

BACKGROUND

Social isolation among older adults raises major issues for equity in healthcare in the context of the COVID-19 pandemic.

MAIN TEXT

This commentary describes current challenges in preventing social isolation among older adults and proposes pathways to develop inclusive approaches to intervention in this vulnerable population. Building interventions that take account of structural inequities among older persons, as well as their subjective experiences, expectations and perspectives, appears fundamental to improve their health and quality of life in pandemic and post-pandemic contexts.

CONCLUSIONS

We argue that equity-based and person-centered approaches are critical to counter the negative outcomes of social isolation in the vulnerable older population.

A Systematic Review of Sociodemographic, Macroeconomic, and Health Resources Factors on Life Expectancy

This review was aimed at systematically synthesizing and appraising the existing literature of sociodemographic, macroeconomic, and health resources factors on life expectancy. A systematic literature search of English databases, that is, PubMed/MEDLINE were scrutinized for exploring sociodemographic, macroeconomic, and health resources factors on life expectancy. The literature search was conducted in January 2020, covering a total of 46 articles from 2004 to 2019 met the review criteria, which were fully discussed subsequently. Among sociodemographic factors, infant mortality rate, literacy rate, education level, socioeconomic status, population growth, and gender inequality have a significant impact on life expectancy. Gross domestic product, Gini, income level, unemployment rate, and inflation rate are the main macroeconomic factors that significantly correlated with life expectancy. Among various health care resources, health care facilities, the number of the health care profession, public health expenditure, death rates, smoking rate, pollution, and vaccinations had a significant correlation with life expectancy. The systematic review showed general conformity of different studies, with a significant association between life expectancy and factors comprising several sociodemographic, macroeconomic, and various health care variables. This review found that only one study examined factors affecting life expectancy in Arabic countries. More studies on this region to fill this research gap were highly recommended.

Education, Healthy Ageing and Vaccine Literacy

Importance and Objective: The Covid pandemic is a timely opportunity to try to broaden our understanding of the links between education and health literacy and explore the vaccine-decision process with a view to identifying interventions that will positively influence vaccine uptake.

EVIDENCE

Health and vaccine literacy encompass people's knowledge, motivation, and competence to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion.

FINDINGS

Appropriate vaccine communication, which depends greatly on personal and contextual determinants, as well as on societal and environmental circumstances, is essential to reassure people about vaccine efficacy, safety, and possible side effects. However, vaccine confidence is not solely a question of trust in the vaccine's efficacy, safety. and individual protective benefit of vaccination. It also encompasses the mechanism(s) of vaccine activity, immunization schedules, organization and trust in the healthcare system that promotes and delivers the vaccines, and at what costs. When healthcare professionals as science brokers of vaccine knowledge attempt to increase vaccine knowledge and confidence, they must adjust their communication to the educational or health literacy level of their intended audience. Even if their messages are apparently clear and simple, they absolutely need to verify that they are properly understood.

RELEVANCE

Specific vaccine communication training appears essential to increase vaccine communication skills among healthcare providers. Moreover, further randomized controlled studies are warranted to improve vaccine empowerment among different populations, from a variety of educational backgrounds.

Augmented wealth in Switzerland: the influence of pension wealth on wealth inequality

Entitlements for social security and occupational pensions present a major wealth component and play a central role for financial security. However, most individual-level data lacks information on pension wealth. By linking various data sources, this contribution estimates the present value of future pension entitlements in Switzerland for statutory pensions, occupational pensions and third pillar accounts and analyses the distribution of augmented wealth, which combines pension wealth and net worth. The CH-SILC survey from 2015 is used to estimate real assets, financial assets and pension wealth of retired individuals. The pension entitlements of non-retired individuals are simulated on the basis of their earning history from administrative records following the accrual method and assuming a real discount rate of 2%. When pension wealth is added to net worth, average wealth doubles, and the Gini-coefficient declines by 26%. The equalising effect is particularly strong for social security pensions. The wealth distribution differs strongly between the three pillars of the pension system; there are also strong differences between gender and age groups. In Switzerland, wealth accumulation continues after retirement age.

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level

INTRODUCTION

First study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective).

METHODS

Data on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged <55 years and men (all ages) showed an increased mortality risk; nonetheless, less educated women aged ≥55 had a reduced risk.

CONCLUSIONS

TAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology

BACKGROUND

In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality.

METHODS

Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII.

FINDINGS

Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere.

CONCLUSIONS

Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

Predictors of Smoking Cessation Attempt and Continued Abstinence among Low-Income Disabled Smokers: Evidence from the French National Smoking Cessation Cohort CDT-Net

Background: In France, daily smoking has been highly prevalent among low-income smokers.Objectives: Our aim was to search for factors associated with both continued abstinence and attempting to quit among low-income disabled smokers. Methods: From the French national smoking cessation cohort CDT-net, we included 1624 adults living with disability pension or disabled adult allowance. Our dependent variables (abstainers, attempting to quit among non-abstainers) were used in logistic regressions. Continued abstinence was defined as self-reports of no smoking for more than 28 days and attempting to quit was defined as self-reports of no smoking for less than 28 days; both validated with carbon monoxide < 10 ppm. Results: The average age was 48.5 years, with a predominance of men (55.5%). Achieved continued abstinence was 29.9% and was positively associated with age ≥ 55, history of previous attempts, low-dependence, and number of consultations during follow-up (all p < .05). Depression history, anxiety symptoms and cannabis use were negatively associated with continued abstinence (p < .05). Quit attempts were associated with lower dependence and number of consultations during follow-up. Pharmacological treatments prescribed at inception did not contribute to improve continued abstinence rates but varenicline was found to increase quit attempts unless the number of prescriptions was scarce. Conclusion: Even among low-income disabled smokers, achieving continued abstinence and attempting to quit could be promoted with similar predictors than among affluent smokers. Treatment of anxiety symptoms and specific support for smokers with a depression history could be included in the follow-up of quit attempts.

Sex differences in health and mortality by income and income changes

BACKGROUND

The adverse association between income, health and survival is well documented, but little is known about how income trajectories influence health and survival for men and women. We aim to investigate sex differences in mortality and hospitalisations by income and income changes.

METHODS

We performed a population-based, nationwide study including 1 063 787 Danes born 1935-1955 and residing in Denmark during 1980-2015. Income was calculated during two age intervals: 45-49 and 55-59 years. The average income was divided into quartiles for men and women separately, which formed the basis for the income trajectories. Individuals were followed up from age 60 until 2014/2015 for hospital admission and mortality, respectively.

RESULTS

Men had higher mortality and were more hospitalised than women. Sex differences in mortality were most pronounced for people with stable low income (relative difference in hazard=1.93; 95% CI 1.89 to 1.98) and a downward income trajectory (1.91; 95% CI 1.85 to 1.98) with smaller sex differences for people with an upward trajectory (1.59; 95% CI 1.56 to 1.62) and stable high income (1.37; 95% CI 1.33 to 1.41). A similar pattern was found for family income. Regarding hospitalisations, similar results were found, though less pronounced. Investigation of mortality and hospitalisations by all possible trajectories demonstrated that income at ages 55-59 was an important predictor of mortality, with increasing mortality for decreasing income quartile.

CONCLUSION

Income trajectories as a proxy for change in social position have a larger influence on men's than women's health and mortality. Income in the late 50s is an important predictor of mortality, particularly for men.