Socioeconomic status and trends in risk factors for cardiovascular diseases in the Danish MONICA population, 1982-1992

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Educational inequality in patient-reported outcomes but not mortality among cardiac patients: Results from the national DenHeart survey with register follow-up

Aims: This study aimed to explore whether educational level is associated with mental and physical health status, anxiety and depression symptoms and quality of life at hospital discharge and predicts cardiac events and all-cause mortality 1 year after hospital discharge in patients with ischaemic heart disease, arrhythmias, heart failure or heart valve disease. Methods: The DenHeart survey is cross-sectional and combined with data from national registers. Information on educational level and co-morbidity at hospital discharge and cardiac events and mortality 1-year post-discharge was obtained from registers. Patient-reported outcomes included SF-12, Hospital Anxiety and Depression Scale and HeartQoL. Multivariate linear and logistic regression and Cox proportional hazards regression models were used. Results: A total of 13,145 patients were included. A significant educational gradient was found in patient-reported mental and physical health status, anxiety and depression symptoms and quality of life, with lower educational groups reporting worse outcomes in adjusted analyses. No association was found between educational level and risk of cardiac events or all-cause mortality within 1 year after hospital discharge in adjusted analyses. Conclusions: In a large population of patients with cardiac disease a significant educational gradient was found in mental and physical health and quality of life at hospital discharge. There was, however, no association between educational level and risk of cardiac events or mortality 1 year after hospital discharge.

Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood

Importance

Surgical removal of adenoids and tonsils to treat obstructed breathing or recurrent middle-ear infections remain common pediatric procedures; however, little is known about their long-term health consequences despite the fact that these lymphatic organs play important roles in the development and function of the immune system.

Objective

To estimate long-term disease risks associated with adenoidectomy, tonsillectomy, and adenotonsillectomy in childhood.

Design, Setting, and Participants

A population-based cohort study of up to 1 189 061 children born in Denmark between 1979 and 1999 and evaluated in linked national registers up to 2009, covering at least the first 10 and up to 30 years of their life, was carried out. Participants in the case and control groups were selected such that their health did not differ significantly prior to surgery.

Exposures

Participants were classified as exposed if adenoids or tonsils were removed within the first 9 years of life.

Main Outcomes and Measures

The incidence of disease (defined by International Classification of Diseases, Eighth Revision [ICD-8] and Tenth Revision [ICD-10] diagnoses) up to age 30 years was examined using stratified Cox proportional hazard regressions that adjusted for 18 covariates, including parental disease history, pregnancy complications, birth weight, Apgar score, sex, socioeconomic markers, and region of Denmark born.

Results

A total of up to 1 189 061 children were included in this study (48% female); 17 460 underwent adenoidectomy, 11 830 tonsillectomy, and 31 377 adenotonsillectomy; 1 157 684 were in the control group. Adenoidectomy and tonsillectomy were associated with a 2- to 3-fold increase in diseases of the upper respiratory tract (relative risk [RR], 1.99; 95% CI, 1.51-2.63 and RR, 2.72; 95% CI, 1.54-4.80; respectively). Smaller increases in risks for infectious and allergic diseases were also found: adenotonsillectomy was associated with a 17% increased risk of infectious diseases (RR, 1.17; 95% CI, 1.10-1.25) corresponding to an absolute risk increase of 2.14% because these diseases are relatively common (12%) in the population. In contrast, the long-term risks for conditions that these surgeries aim to treat often did not differ significantly and were sometimes lower or higher.

Conclusions and Relevance

In this study of almost 1.2 million children, of whom 17 460 had adenoidectomy, 11 830 tonsillectomy, and 31 377 adenotonsillectomy, surgeries were associated with increased long-term risks of respiratory, infectious, and allergic diseases. Although rigorous controls for confounding were used where such data were available, it is possible these effects could not be fully accounted for. Our results suggest it is important to consider long-term risks when making decisions to perform tonsillectomy or adenoidectomy.

Association of socioeconomic status and hypertension based on habitual smoking among Iranian population: IHHP study

BACKGROUND

Along with tripartiteclose relationship of socioeconomic level,  smoking, and prevalence of hypertension, the present study aimed to assess the relationship between socioeconomic status (SES) and hypertension based on habitual smoking in Iranian population. Methods: The present study analyzed the individuals subsample consisted of 9623 subjects, out of all people resident in Isfahan province in Iran of the wave of the Isfahan Heart Health Project (IHHP) in three cities in Iran: Isfahan, Najafabad and Arak. Systolic and diastolic blood pressures were measured in supine position using an automated blood pressure monitor. Smokers were defined as persons who were smoked prior to the survey and never smokers were defined as a person who had never smoked.  Results: Those individuals who experienced cigarette smoking, SES class was significantly lower in hypertensive patients compared with normotensive subject so 7.8% of hypertensive patients and 92.2% of normotensive ones classified in SES class IV (p < 0.001). Univariate analysis showed hypertension was related to lower SES class when compared with normotension status in both smoker and nonsmoker groups (p < 0.001). In stepwise logistic regression models adjusting sex, age, global dietary index and leisure time physical activity, hypertension could be predicted by lower SES in nonsmoker group, while this predictive role for SES could not be reveal in smoker group.  Conclusion: the significant SES-smoking association may determinate in the increasing blood pressure even adjusted for other covariates such as demographics as well as dietary behaviors and leisure time physical activity.

Socioeconomic status and trends in alcohol drinking in the Danish MONICA population, 1982- 92

Aims: To examine trends in alcohol drinking in different educational groups.

Methods: Data from three cross-sectional WHO MONICA surveys conducted in 1982-84, 1987, and 1991-92 were analysed to estimate trends in abstention, moderate, heavy, and sporadic heavy alcohol use in relation to level of education, age and smoking. In total, 6,695 Danish men and women aged 30, 40, 50, and 60 years were included.

Results: Alcohol drinking decreased in both men and women during the study period, but changes were only significant among the highest educated. In the highest educated men the prevalence of moderate alcohol use increased from 77 to 82%, while heavy alcohol use declined from 19 to 12%. In the highest educated women the prevalence of abstention increased from 15 to 22%, while moderate alcohol use declined from 78 to 68%.

Conclusion: During the 1980s, alcohol drinking decreased among the highest educated men and women and an educational gradient in alcohol drinking widened in men and attenuated in women.

Cardiovascular Risk Factors in Iranian Adults according to Educational Levels: Isfahan Healthy Heart Program

There is abundant evidence that the socioeconomic status (SES) is inversely associated with CVD risk factors. The objective of this study is to describe the distribution of CVD risk factors according to educational level in Iranian adults. A cross-sectional survey was performed on subjects over the age of 19 in three cities. Demographic data, as well as information on educational level and smoking habits was obtained and then height, weight and blood pressure measurement and blood sampling were arranged. Data was analyzed by the Mantel-Haenszel, Kendalls T correlation and multivariate analysis test. Of 9587 subjects, 48% were men and 52% were women, with mean ages of 39.0±15.3 and 38.8±14.5 years, respectively. All CVD risk factors showed an inverse relationship with educational level in all subjects, except for smoking and low HDL-C in women. High TC and LDL-C and low HDL-C were inversely related to educational level (P<0.05); however, this relationship was not significant with Mantel-Haenszel test in men. The association between CVD risk factors and educational level in women was stronger than in men. The differences found between CVD risk factors with educational level are important and should be considered in programs designed to increase level of education in order to lower CVD risk factors. Asia Pac J Public Health 2005: 17(1): 9-14.

Defining the Path Between Social and Economic Factors, Clinical and Lifestyle Determinants, and Cardiovascular Disease

BACKGROUND

Low socioeconomic status is associated with poorer cardiovascular health.

OBJECTIVES

The aim of the present work was to evaluate how social and economic factors influence modifiable cardiovascular disease risk factors and thus, acute coronary syndrome or ischemic stroke presence.

METHODS

One thousand participants were enrolled; 250 consecutive patients with a first acute coronary syndrome (83% were male, 60 ± 12 years old) and 250 control subjects, as well as 250 consecutive patients with a first ischemic stroke (56% were male, 77 ± 9 years old) and 250 control subjects. The control subjects were population-based and age-sex matched with the patients. Detailed information regarding their medical records, lifestyle characteristics, education level, financial status satisfaction, and type of occupation were recorded.

RESULTS

After controlling for potential confounding factors, significant inverse associations were observed regarding financial status satisfaction and sedentary/mental type occupation with acute coronary syndrome or stroke presence, but not with the educational level. Nevertheless, further evaluation using path analysis, revealed quite different results, indicating that the education level influenced the type of occupation and financial satisfaction, hence affecting indirectly the likelihood of developing a cardiovascular disease event.

CONCLUSIONS

Social and economic parameters interact with modifiable cardiovascular disease risk factors through multiple pathways.

The association between family affluence and smoking among 15-year-old adolescents in 33 European countries, Israel and Canada: the role of national wealth

AIMS

To examine the role of national wealth in the association between family affluence and adolescent weekly smoking, early smoking behaviour and weekly smoking among former experimenters.

DESIGN AND PARTICIPANTS

Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 in 35 countries from Europe and North America that comprises 60 490 students aged 15 years. Multi-level logistic regression was conducted using Markov chain Monte Carlo methods (MCMC) to explore whether associations between family affluence and smoking outcomes were dependent upon national wealth.

MEASUREMENT

Family Affluence Scale (FAS) as an indicator for the socio-economic position of students. Current weekly smoking behaviour is defined as at least weekly smoking (dichotomous). Early smoking behaviour is measured by smoking more than a first puff before age 13 years (dichotomous). Weekly smoking among former experimenters is restricted to those who had tried a first puff in the past.

FINDINGS

The logistic multi-level models indicated an association of family affluence with current weekly smoking [odds ratio (OR) = 1.088; 95% credible interval (CrI) = 1.055-1.121, P < 0.001], early smoking behaviour (OR = 1.066; CrI = 1.028-1.104, P < 0.001) and smoking among former experimenters (OR = 1.100; CrI = 1.071-1.130; P < 0.001). Gross domestic product (GDP) per capita was associated positively and significantly with the relationship between family affluence and current weekly smoking (OR = 1.005; CrI = 1.003-1.007; P < 0.001), early smoking behaviour (OR = 1.003; CrI = 1.000-1.005; P = 0.012) and smoking among former experimenters (OR = 1.004; CrI = 1.002-1.006; P < 0.001). The association of family affluence and smoking outcomes was significantly stronger for girls.

CONCLUSIONS

The difference in smoking prevalence between rich and poor is greater in more affluent countries.

Disparities in dietary habits and physical activity in Denmark and trends from 1995 to 2008

Aims: To examine social disparities in dietary-, alcohol- and leisure-time physical activity habits in Danish adults from 1995 to 2008 and to test the hypothesis of widening disparities. Methods: Four cross-sectional surveys of representative samples of the Danish population aged 20–75 years were analysed, a total of 7900 respondents. Dietary and alcohol habits were measured by a 7-day pre-coded food diary and physical activity and education by a face-to-face interview. Multivariate analyses were used to test associations between explanatory variables and response variables and the hypothesis of widening disparities. Results: In all analyses, both diet quality and physical inactivity differed systematically with educational group and with healthier habits for the group with long education. Only for alcohol habits was an opposite social gradient seen. Disparities persisted over all time periods. The analyses using “The Concentration Index” did not change any of the conclusions. Gender also influenced diet quality. Men had dietary and alcohol habits furthest away from the guidelines. A trend of healthier habits was also found over the time period. Conclusions: Social disparities in diet quality and leisure-time physical activity were seen for all examined time periods and with no significant change. Therefore, there is no support to the hypothesis of widening social disparities. In all educational groups some improvement of dietary habits was found, especially for those foods where comprehensive initiatives had taken place. However, social disparities still exist. There is an ongoing need to address these disparities in order to reduce social inequality in health.

Surveillance of social and geographic inequalities in housing-related issues: the case of the Eastern Townships, Quebec (Canada)

Even though health inequalities are conditioned by many aspects of the environment, much of the existing research focuses on the social environment. This emphasis has the effect to neglect other environmental aspects such as its physical dimension. The physical environment, which is linked to housing conditions, may contribute to the uneven distribution of health. In this study, we examined 19 housing-related issues among a representative sample of 2,000 adults residing in a Quebec (Canada) health region characterized by a mix of rural, semi-rural, and urban areas. The distribution of these issues was examined according to socioeconomic and geographic indicators of social position. Summary measures of inequalities were assessed. Our results showed that the prevalence of nearly all housing-related issues was higher among low-income households compared to more affluent ones. Highly educated individuals showed better housing conditions, whereas different issues tended to cluster in deprived or densely populated areas. To conclude, we observed steep gradients between social class and poor housing conditions. This may explain a substantial part of health inequality on the regional scale. The surveillance of housing-related issues is therefore essential to properly inform and mobilize local stakeholders and to develop interventions that target vulnerable groups on this level.

The contribution of educational class in improving accuracy of cardiovascular risk prediction across European regions: The MORGAM Project Cohort Component

OBJECTIVE

To assess whether educational class, an index of socioeconomic position, improves the accuracy of the SCORE cardiovascular disease (CVD) risk prediction equation.

METHODS

In a pooled analysis of 68 455 40-64-year-old men and women, free from coronary heart disease at baseline, from 47 prospective population-based cohorts from Nordic countries (Finland, Denmark, Sweden), the UK (Northern Ireland, Scotland), Central Europe (France, Germany, Italy) and Eastern Europe (Lithuania, Poland) and Russia, we assessed improvements in discrimination and in risk classification (net reclassification improvement (NRI)) when education was added to models including the SCORE risk equation.

RESULTS

The lowest educational class was associated with higher CVD mortality in men (pooled age-adjusted HR=1.64, 95% CI 1.42 to 1.90) and women (HR=1.31, 1.02 to 1.68). In men, the HRs ranged from 1.3 (Central Europe) to 2.1 (Eastern Europe and Russia). After adjustment for the SCORE risk, the association remained statistically significant overall, in the UK and Eastern Europe and Russia. Education significantly improved discrimination in all European regions and classification in Nordic countries (clinical NRI=5.3%) and in Eastern Europe and Russia (NRI=24.7%). In women, after SCORE risk adjustment, the association was not statistically significant, but the reduced number of deaths plays a major role, and the addition of education led to improvements in discrimination and classification in the Nordic countries only.

CONCLUSIONS

We recommend the inclusion of education in SCORE CVD risk equation in men, particularly in Nordic and East European countries, to improve social equity in primary prevention. Weaker evidence for women warrants the need for further investigations.

Trends in smoking in Canada from 1950 to 2011: progression of the tobacco epidemic according to socioeconomic status and geography

PURPOSE

Smoking has declined in Canada in recent years. However, it is not clear whether differences in current smoking by socioeconomic status have increased, decreased, or remained unchanged in Canada.

METHODS

We examined rates of current smoking by sex, education, and province from 1950 to 2011. Differences in current smoking, initiation, and cessation were summarized using relative and absolute measures.

RESULTS

Between 1950 and 2011, the prevalence of current smoking (including daily and non-daily) among adults aged 20 years and older decreased steadily in men from 68.9 % (95 % CI 63.9-73.3) to 18.6 % (14.9-22.1) but in women increased slightly from 38.2 % (32.3-42.2) in 1950 to 39.1 % (36.4-41.2) in 1959 before declining to 15.4 % (11.9-18.9) in 2011. Among men, there was an inverse association between educational attainment and smoking which was consistent from 1950 to 2011. A similar gradient emerged in the mid-1960s in women. Absolute differences in rates of smoking across levels of education increased despite overall declines in smoking across all levels of education. Rates of smoking in women and men were higher in the Atlantic Provinces and Quebec, although in men these differences have declined since the 1990s. In a subset of data from 1999 to 2011, those with lower levels of education had higher levels of smoking initiation and lower levels of cessation.

CONCLUSIONS

Smoking rates have fallen over time but socioeconomic differences have increased. Smoking prevalence peaked later in lower socioeconomic status (SES) groups, and rates of decline in lower SES groups and certain provinces have been less steep. This suggests that SES gradients emerge rapidly in later stages of the tobacco epidemic and may have increased through greater efficacy of tobacco control policies in reducing smoking among those of higher SES compared to those of lower SES. Tailored approaches may be required to reduce smoking rates in those of lower SES and narrow SES differences.

Inequalities in non-communicable diseases and effective responses

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: a systematic review

Background

This study systematically reviewed the evidence pertaining to socioeconomic inequalities in different domains of physical activity (PA) by European region.

Methods

Studies conducted between January 2000 and December 2010 were identified by a systematic search in Pubmed, Embase, Web of Science, Psychinfo, Sportdiscus, Sociological Abstracts, and Social Service Abstracts. English-language peer-reviewed studies undertaken in the general population of adults (18–65 years) were classified by domain of PA (total, leisure-time including sport, occupational, active transport), indicator of socioeconomic position (education, income, occupation), and European region. Distributions of reported positive, negative, and null associations were evaluated.

Results

A total of 131 studies met the inclusion criteria. Most studies were conducted in Scandinavia (n = 47). Leisure-time PA was the most frequently studied PA outcome (n = 112). Considerable differences in the direction of inequalities were seen for the different domains of PA. Most studies reported that those with high socioeconomic position were more physically active during leisure-time compared to those with low socioeconomic position (68% positive associations for total leisure-time PA, 76% for vigorous leisure-time PA). Occupational PA was more prevalent among the lower socioeconomic groups (63% negative associations). Socioeconomic differences in total PA and active transport PA did not show a consistent pattern (40% and 38% positive associations respectively). Some inequalities differed by European region or socioeconomic indicator, however these differences were not very pronounced.

Conclusions

The direction of socioeconomic inequalities in PA in Europe differed considerably by domain of PA. The contradictory results for total PA may partly be explained by contrasting socioeconomic patterns for leisure-time PA and occupational PA.

Lower educational level is a predictor of incident type 2 diabetes in European countries: the EPIC-InterAct study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases worldwide. In high-income countries, low socioeconomic status seems to be related to a high incidence of T2DM, but very little is known about the intermediate factors of this relationship. Method We performed a case-cohort study in eight Western European countries nested in the EPIC study (n = 340, 234, 3.99 million person-years of follow-up). A random sub-cohort of 16,835 individuals and a total of 12,403 incident cases of T2DM were identified. Crude and multivariate-adjusted hazard ratios (HR) were estimated for each country and pooled across countries using meta-analytical methods. Age-, gender- and country-specific relative indices of inequality (RII) were used as the measure of educational level and RII tertiles were analysed.

RESULTS

Compared with participants with a high educational level (RII tertile 1), participants with a low educational level (RII tertile 3) had a higher risk of T2DM [HR: 1.77, 95% confidence interval (CI): 1.69-1.85; P-trend < 0.01]. The HRs adjusted for physical activity, smoking status and propensity score according to macronutrient intake were very similar to the crude HR (adjusted HR: 1.67, 95% CI: 1.52-1.83 in men; HR: 1.88, 95% CI: 1.73-2.05 in women). The HRs were attenuated only when they were further adjusted for BMI (BMI-adjusted HR: 1.36, 95% CI: 1.23-1.51 in men; HR: 1.32, 95% CI: 1.20-1.45 in women).

CONCLUSION

This study demonstrates the inequalities in the risk of T2DM in Western European countries, with an inverse relationship between educational level and risk of T2DM that is only partially explained by variations in BMI.

Trends in socioeconomic inequalities in smoking prevalence, consumption, initiation, and cessation between 2001 and 2008 in the Netherlands. Findings from a national population survey

Background

Widening of socioeconomic status (SES) inequalities in smoking prevalence has occurred in several Western countries from the mid 1970’s onwards. However, little is known about a widening of SES inequalities in smoking consumption, initiation and cessation.

Methods

Repeated cross-sectional population surveys from 2001 to 2008 (n ≈ 18,000 per year) were used to examine changes in smoking prevalence, smoking consumption (number of cigarettes per day), initiation ratios (ratio of ever smokers to all respondents), and quit ratios (ratio of former smokers to ever smokers) in the Netherlands. Education level and income level were used as indicators of SES and results were reported separately for men and women.

Results

Lower educated respondents were significantly more likely to be smokers, smoked more cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated respondents. Income inequalities were smaller than educational inequalities and were not all significant, but were in the same direction as educational inequalities. Among women, educational inequalities widened significantly between 2001 and 2008 for smoking prevalence, smoking initiation, and smoking cessation. Among low educated women, smoking prevalence remained stable between 2001 and 2008 because both the initiation and quit ratio increased significantly. Among moderate and high educated women, smoking prevalence decreased significantly because initiation ratios remained constant, while quit ratios increased significantly. Among men, educational inequalities widened significantly between 2001 and 2008 for smoking consumption only.

Conclusions

While inequalities in smoking prevalence were stable among Dutch men, they increased among women, due to widening inequalities in both smoking cessation and initiation. Both components should be addressed in equity-oriented tobacco control policies.

Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984-2008

Background

There has been an overall decrease in incident ischaemic heart disease (IHD), but the reduction in IHD risk factors has been greater among those with higher social position. Increased social inequalities in IHD mortality in Scandinavian countries is often referred to as the Scandinavian “public health puzzle”. The objective of this study was to examine trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors (smoking, diabetes, hypertension and high total cholesterol) over the last three decades among Norwegian middle-aged women and men.

Methods

Population-based, cross-sectional data from The Nord-Trøndelag Health Study (HUNT): HUNT 1 (1984–1986), HUNT 2 (1995–1997) and HUNT 3 (2006–2008), women and men 40–59 years old. Educational inequalities were assessed using the Slope Index of Inequality (SII) and The Relative Index of Inequality (RII).

Results

Smoking prevalence increased for all education groups among women and decreased in men. Relative and absolute educational inequalities in smoking widened in both genders, with significantly higher absolute inequalities among women than men in the two last surveys. Diabetes prevalence increased in all groups. Relative inequalities in diabetes were stable, while absolute inequalities increased both among women (p = 0.05) and among men (p = 0.01). Hypertension prevalence decreased in all groups. Relative inequalities in hypertension widened over time in both genders. However, absolute inequalities in hypertension decreased among women (p = 0.05) and were stable among men (p = 0.33). For high total cholesterol relative and absolute inequalities remained stable in both genders.

Conclusion

Widening absolute educational inequalities in smoking and diabetes over the last three decades gives rise to concern. The mechanisms behind these results are less clear, and future studies are needed to assess if educational inequalities in secondary prevention of IHD are larger compared to educational inequalities in primary prevention of IHD. Continued monitoring of IHD risk factors at the population level is therefore warranted. The results emphasise the need for public health efforts to prevent future burdens of life-style-related diseases and to avoid further widening in socioeconomic inequalities in IHD mortality in Norway, especially among women.

Regional surveillance of social and geographic inequalities in smoking: the case of Montréal, Canada

Surveillance of social inequalities in health is a platform for action. We examined the trends in smoking behaviours (current and ever smoking, quit ratios) according to education and place of residence and we quantified the observed inequalities. Data were from repeated cross-sectional surveys (2003-2009) of Montreal (Canada) residents ≥15 years (n=12,053). Trends in smoking behaviours according to education were measured with logistic and log-binomial regressions. Spatial distribution of smoking behaviours across local areas was assessed with Morans' Index. Observed inequalities were quantified with prevalence ratio and difference, population attributable risk, and slope index of inequality. Results showed that ever smoking rose among low-educated individuals. Among their high-educated fellow-citizens, current smoking decreased and quit ratios increased. Adverse smoking behaviours (current and ever smoking) were clustered in south-central areas. We conclude that smoking inequalities in Montreal are growing. We thus encourage a closer monitoring of smoking social differentials.

Social class differences in secular trends in established coronary risk factors over 20 years: a cohort study of British men from 1978-80 to 1998-2000

BACKGROUND

Coronary heart disease (CHD) mortality in the UK since the late 1970s has declined more markedly among higher socioeconomic groups. However, little is known about changes in coronary risk factors in different socioeconomic groups. This study examined whether changes in established coronary risk factors in Britain over 20 years between 1978-80 and 1998-2000 differed between socioeconomic groups.

METHODS AND FINDINGS

A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-80 to 1998-2000; data on blood pressure (BP), cholesterol, body mass index (BMI) and cigarette smoking were collected at both points in 4252 survivors. Social class was based on longest-held occupation in middle-age. Compared with men in non-manual occupations, men in manual occupations experienced a greater increase in BMI (mean difference = 0.33 kg/m(2); 95%CI 0.14-0.53; p for interaction = 0.001), a smaller decline in non-HDL cholesterol (difference in mean change = 0.18 mmol/l; 95%CI 0.11-0.25, p for interaction≤0.0001) and a smaller increase in HDL cholesterol (difference in mean change = 0.04 mmol/l; 95%CI 0.02-0.06, p for interaction≤0.0001). However, mean systolic BP declined more in manual than non-manual groups (difference in mean change = 3.6; 95%CI 2.1-5.1, p for interaction≤0.0001). The odds of being a current smoker in 1978-80 and 1998-2000 did not differ between non-manual and manual social classes (p for interaction = 0.51).

CONCLUSION

Several key risk factors for CHD and type 2 diabetes showed less favourable changes in men in manual occupations. Continuing priority is needed to improve adverse cardiovascular risk profiles in socially disadvantaged groups in the UK.

Trends in the prevalence, awareness, treatment, and control of cardiovascular risk factors across educational level in the 1995-2005 period

PURPOSE

To determine the differences and trends in the prevalence, awareness, treatment and control of cardiovascular risk factors and lifestyle variables across educational level in the 1995-2005 period in a country with a universal free health care system.

METHODS

Data from three consecutive independent population-based surveys were used. Cardiovascular risk factors, lifestyle variables, and self-reported educational level were collected in 9646 individuals ages 35-74 years throughout the decade.

RESULTS

The prevalence of hypertension and diabetes was inversely associated with education. An increase in the proportion of hypertension and dyslipidemia awareness, treatment, and control in all educational level groups was observed. This increase was greater among the lowest education group, reducing the disparities between groups. The prevalence of lifestyle-related risk factors decreased in the greatest but increased in the lowest education group, widening the disparities between groups.

CONCLUSIONS

A universal free health care system is effective in avoiding inequalities in the diagnosis, treatment, and control of cardiovascular risk factors. However, other social determinants seem to explain the social inequalities in the prevalence of these risk factors and in the adoption of healthy lifestyles.

National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants

BACKGROUND

Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. However, few worldwide analyses of trends in blood pressure have been done. We estimated worldwide trends in population mean systolic blood pressure (SBP).

METHODS

We estimated trends and their uncertainties in mean SBP for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (786 country-years and 5·4 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean SBP by age, country, and year, accounting for whether a study was nationally representative.

FINDINGS

In 2008, age-standardised mean SBP worldwide was 128·1 mm Hg (95% uncertainty interval 126·7-129·4) in men and 124·4 mm Hg (123·0-125·9) in women. Globally, between 1980 and 2008, SBP decreased by 0·8 mm Hg per decade (-0·4 to 2·2, posterior probability of being a true decline=0·90) in men and 1·0 mm Hg per decade (-0·3 to 2·3, posterior probability=0·93) in women. Female SBP decreased by 3·5 mm Hg or more per decade in western Europe and Australasia (posterior probabilities ≥0·999). Male SBP fell most in high-income North America, by 2·8 mm Hg per decade (1·3-4·5, posterior probability >0·999), followed by Australasia and western Europe where it decreased by more than 2·0 mm Hg per decade (posterior probabilities >0·98). SBP rose in Oceania, east Africa, and south and southeast Asia for both sexes, and in west Africa for women, with the increases ranging 0·8-1·6 mm Hg per decade in men (posterior probabilities 0·72-0·91) and 1·0-2·7 mm Hg per decade for women (posterior probabilities 0·75-0·98). Female SBP was highest in some east and west African countries, with means of 135 mm Hg or greater. Male SBP was highest in Baltic and east and west African countries, where mean SBP reached 138 mm Hg or more. Men and women in western Europe had the highest SBP in high-income regions.

INTERPRETATION

On average, global population SBP decreased slightly since 1980, but trends varied significantly across regions and countries. SBP is currently highest in low-income and middle-income countries. Effective population-based and personal interventions should be targeted towards low-income and middle-income countries.

FUNDING

Funding Bill & Melinda Gates Foundation and WHO.

Cardiovascular disease occurrence in two close but different social environments

Background

Cardiovascular diseases estimate to be the leading cause of death and loss of disability-adjusted life years globally. Conventional risk factors for cardiovascular diseases only partly account for the social gradient. The purpose of this study was to compare the occurrence of the most frequent cardiovascular diseases and cardiovascular mortality in two close cities, the Twin cities.

Methods

We focused on the total population in two neighbour and equally sized cities with a population of around 135 000 inhabitants each. These twin cities represent two different social environments in the same Swedish county. According to their social history they could be labelled a "blue-collar" and a "white-collar" city. Morbidity data for the two cities was derived from an administrative health care register based on medical records assigned by the physicians at both hospitals and primary care. The morbidity data presented are cumulative incidence rates and the data on mortality for ischemic heart diseases is based on official Swedish statistics.

Results

The cumulative incidence of different cardiovascular diagnoses for younger and also elderly men and women revealed significantly differences for studied cardiovascular diagnoses. The occurrence rates were in all aspects highest in the population of the "blue-collar" twin city for both sexes.

Conclusions

This study revealed that there are significant differences in risk for cardiovascular morbidity and mortality between the populations in the studied different social environments. These differences seem to be profound and stable over time and thereby give implication for public health policy to initiate a community intervention program in the "blue-collar" twin city.

Social determinants and the decline of cardiovascular diseases: understanding the links

This article reviews the historical declines in cardiovascular mortality and provides an overview of the contribution of social and economic factors to disease change. We document the magnitude of declines in cardiovascular diseases and the major role of changes in conventional risk factors, and we review the contributions of social determinants to changes in disease rates. We conclude by arguing that understanding patterns and trends of social inequalities in cardiovascular disease and its risk factors requires consideration of the specific intersections of health and social exposures acting across the life course in different settings, in both time and place.

Association of Median Household Income With Burden of Coronary Artery Disease Among Individuals With Diabetes

Background— Low income is associated with adverse cardiovascular outcomes. Diabetes is more prevalent among low income groups, and low income patients with diabetes have been shown to have a greater burden of cardiovascular risk factors and worse cardiovascular outcomes. The objective of this study was to determine whether income status was associated with burden of coronary atherosclerosis in patients with diabetes.

Methods and Results— All patients with diabetes presenting for cardiac catheterization between January 1, 2000, and December 31, 2002, in Calgary, Canada, were identified through the use of the Alberta Provincial Project for Assessing Outcomes in Coronary Heart Disease (APPROACH) database. This clinical database was merged with Canadian 2001 Census data on median household income per dissemination area using patient postal code data, and income quintiles were derived. Clinical profiles, severity of coronary atherosclerosis, and myocardial jeopardy were compared across income quintiles. Mean scores for severity and jeopardy were compared across income quintiles using analysis of variance. Multivariate linear regression was used to control for baseline differences across income groups.

A total of 4596 patients were eligible for inclusion in this study. Clinical profiles differed significantly across income quintiles, with the highest income quintile being younger ( P <0.0005), more likely to be male ( P =0.029), and having a lower prevalence of smoking ( P =0. 039). Low income groups were more likely to report a history of myocardial infarction ( P <0.0005) or congestive heart failure ( P <0.0005). The highest income groups has significantly less coronary atherosclerosis as measured by the weighted Duke index (6.67 versus 7.38, P <0.002), but there were no differences in lesion severity as measured by the Duke severity scale (2.31 versus 2.41, P =0.334). High income patients has significantly less myocardial jeopardy compared with the lowest income group as measured by the Duke and APPROACH scores (36.44 versus 46.23, P =0.0187, and 39.96 versus 45.36, P =0.0182, respectively). These differences remained significant even after controlling for baseline clinical differences in cardiovascular risk factor burden.

Conclusions— Low income is associated with a greater degree of atherosclerosis and greater myocardial jeopardy in patients with diabetes. More needs to be done to reduce cardiovascular risk factor burden in this vulnerable population.

Social inequality in adolescent daily smoking: has it changed over time?

BACKGROUND AND AIM

In most northern European countries adolescent smoking is most prevalent in lower social classes but there is little information about time trends in social inequality. This paper describes trends in social inequality in daily smoking among adolescents from 1991 to 2006 by both absolute social inequality (prevalence difference between low and high social class) and relative social inequality (prevalence ratio).

METHODS

We analysed 15-year-olds from the Health Behaviour in School-aged Children (HBSC) study in Denmark in 1991, 1994, 1998, 2002 and 2006, total n = 6703. The surveys were comparable because of similar procedures for sampling, data collection, and measurements of smoking and parents' occupational social class.

FINDINGS

From 1991 to 2006 the prevalence of daily smoking decreased from 15.9% to 10.9% among boys and from 20.1% to 10.6% among girls. The social inequality fluctuated over time and was different for boys and for girls. The prevalence difference between boys from low and high social class was 5.2% in 1991 and 9.3% in 2006, corresponding figures for girls were 4.8% and 7.0%. The prevalence ratio among boys was 1.38 (in 1991) and 2.19 (in 2006), among girls 1.28 and 1.95.

CONCLUSIONS

Daily smoking was most prevalent among students from lower social classes and the level of inequality fluctuated over time. Conclusions on social inequality in adolescent smoking may appear differently when described by absolute and relative measures. The absolute and relative social inequality in adolescent smoking was higher in 2006 than in 1991.

Patterns of smoking according to individual social position, and to socio-economic environment in municipal areas, Spain 1987-2001

We analyzed the impact of municipal areas socio-economic environment and trends in inequalities in smoking in Spain, 1987-2001. Inequalities in smoking have increased in both sexes. In males are the result of a higher decrease in the prevalence of smoking among the most advantaged groups, and in women, it is due to a higher increase among the less advantaged groups. Males residing in more deprived areas have a higher likelihood of smoking. For women, the likelihood of smoking is higher when residing in less deprived municipal areas up to 1995/1997. Individual and environmental social factors are relevant for smoking in Spain.

Use of statins and beta-blockers after acute myocardial infarction according to income and education

OBJECTIVE

To study the initiation of and long-term refill persistency with statins and beta-blockers after acute myocardial infarction (AMI) according to income and education.

DESIGN AND SETTING

Linkage of individuals through national registers of hospitalisations, drug dispensation, income and education.

PARTICIPANTS

30 078 patients aged 30-74 years surviving first hospitalisation for AMI in Denmark between 1995 and 2001.

MAIN OUTCOME MEASURES

Initiation of statin or beta-blocker treatment (out-patient claim of prescriptions within 6 months of discharge) and refill persistency (first break in treatment lasting at least 90 days, and re-initiation of treatment after a break).

RESULTS

When simultaneously estimating the effect of income and education on initiation of treatment, the effect of education attenuated and a clear income gradient remained for both drugs. Among patients aged 30-64 years, high income (adjusted hazard ratio (HR) 1.27; 95% confidence interval (CI) 1.19-1.35) and medium income (HR 1.13; 95% CI 1.06-1.20) was associated with initiation of statin treatment compared with low income. The risk of break in statin treatment was lower for patients with high (HR 0.73; 95% CI 0.66-0.82) and medium (HR 0.82; 95% CI 0.74-0.92) income compared with low income, whereas there was a trend in the opposite direction concerning a break in beta-blocker treatment. There was no gradient in re-initiation of treatment.

CONCLUSION

Patients with low compared with high income less frequently initiated preventive treatment post-AMI, had worse long-term persistency with statins, but tended to have better persistency with beta-blockers. Low income by itself seems not to be associated with poor long-term refill persistency post-AMI.

Clusters of lifestyle behaviors: results from the Dutch SMILE study

OBJECTIVE

This study aimed to identify differences and similarities in health behavior clusters for respondents with different educational backgrounds.

METHODS

A total of 9449 respondents from the 2002 wave of the Dutch SMILE cohort study participated. Latent class analyses were used to identify clusters of people based on their adherence to Dutch recommendations for five important preventive health behaviors: non-smoking, alcohol use, fruit consumption, vegetable consumption and physical exercise.

RESULTS

The distribution of these groups of behaviors resulted in three clusters of people: a healthy, an unhealthy and poor nutrition cluster. This pattern was replicated in groups with low, moderate and high educational background. The high educational group scored much better on all health behaviors, whereas the lowest educational group scored the worst on the health behaviors.

CONCLUSION

The same three patterns of health behavior can be found in different educational groups (high, moderate, low). The high educational group scored much better on all health behaviors, whereas the lowest educational group scored the worst on the health behaviors. Tailoring health education messages using a cluster-based approach may be a promising new approach to address multiple behavior change more effectively.

[Health inequalities in Korea: current conditions and implications]

OBJECTIVES

The aim of this study is to summarize the current conditions and implications of health inequalities in South Korea.

METHODS

Through a literature review of empirical studies and supplementary analysis of the data presented in the 1998, 2001, and 2005 KNHANEs, we evaluated the extent and trends of socioeconomic inequalities in both health risk factors, such as smoking, physical activity, and obesity, and outcomes, such as total mortality, subjective poor health status by self-reports and metabolic syndrome. Relative risks and odds ratios were used to measure differences across socioeconomic groups, and the relative index of inequality was used to evaluate the changes in inequalities over time.

RESULTS

We found clear inequalities to various degrees in most health indicators. While little change was observed in mortality differences over time, the socioeconomic gaps in risk factors and morbidity have been widening, with much larger differences among the younger population.

CONCLUSIONS

Socioeconomic inequalities are pervasive across various health indicators, and some of them are increasing. The trends in socioeconomic inequalities in health should be carefully monitored, and comprehensive measures to alleviate health inequalities are needed, especially for young populations.

The effects of socio-economic status on BMI, waist:hip ratio and waist circumference in a group of Iranian women

OBJECTIVE

To assess the effects of socio-economic status (SES) on BMI, waist:hip ratio (WHR) and waist circumference (WC) in a group of Iranian women.

METHODS

A cross-sectional study was conducted on 888 women in Sistan and Baluchestan Province. SES was measured using level of education. In addition, parity, marital status and physical activity were assessed. Standardized measurements were taken, BMI and WHR were calculated.

RESULTS

Low education level was a strong determinant of overweight and obesity among Iranian women. After controlling for age, women with higher education level had significantly lower BMI, WC and parity. Multiple linear regression analysis found a significant negative association of BMI and WC with education level and a significant positive association of BMI and WC with parity. Significant factors associated with obesity by a logistic regression model were education level (OR for university graduates v. illiterate or low literacy levels: 1.00 v. 3.70; P = 0.01), living with spouse (OR for married v. single subjects: 1.00 v. 0.15; P = 0.05), parity (OR for more than five v. less than two pregnancies: 1.00 v. 0.34; P = 0.03) and WC (OR for < 0.88 cm v. > or = 0.88 cm: 1.00 v. 11.20; P = 0.001).

CONCLUSION

The present study revealed that educational level, multiple pregnancies, marital status and lack of exercise are some possible explanations for the obesity among Sistan and Baluchestan women.

Relationship between health-related fitness and educational and income levels in Spanish women

OBJECTIVES

The aim of this study was to determine whether a relationship exists between health-related fitness, taken as an indicator of regular physical activity, and educational and income levels in adult Spanish women.

STUDY DESIGN

Descriptive, correlation, cross-sectional study.

METHODS

A stepwise stratification procedure according to population size, age and level of physical activity according to a previous epidemiological survey was used for sampling. Two thousand and thirty-eight women gave their written consent to participate (62.8% of those invited). The final sample consisted of 1709 healthy women (aged 18-88 years). Subjects were categorized into high, medium and low level groups for education and income. All participants were assessed for morphological and physical health-related fitness. Three-way MANCOVA (age as covariate) and Bonferroni's post hoc test were used to determine the differences between groups.

RESULTS

No significant relationships were found between age-adjusted educational and income levels. The lowest values for health-related fitness were found in the lowest educational and income groups (P<0.001). The higher the level of education and income, the better the values for all fitness variables (P<0.001), except anterior trunk flexibility.

CONCLUSIONS

A positive relationship was found between health-related fitness and educational and income levels, which appeared to be most evident in the lowest educational and income groups. This implies that health-related promotion policies in Spain should stress the importance of regular physical activity in social classes with low levels of education and income.

Educational status and cardiovascular risk profile in Indians

The inverse graded relationship of education and risk factors of coronary heart disease (CHD) has been reported from Western populations. To examine whether risk factors of CHD are predicted by level of education and influenced by the level of urbanization in Indian industrial populations, a cross-sectional survey (n = 19,973; response rate, 87.6%) was carried out among employees and their family members in 10 medium-to-large industries in highly urban, urban, and periurban regions of India. Information on behavioral, clinical, and biochemical risk factors of CHD was obtained through standardized instruments, and educational status was assessed in terms of the highest educational level attained. Data from 19,969 individuals were used for analysis. Tobacco use and hypertension were significantly more prevalent in the low- (56.6% and 33.8%, respectively) compared with the high-education group (12.5% and 22.7%, respectively; P < 0.001). However, dyslipidemia prevalence was significantly higher in the high-education group (27.1% as compared with 16.9% in the lowest-education group; P < 0.01). When stratified by the level of urbanization, industrial populations located in highly urbanized centers were observed to have an inverse graded relationship (i.e., higher-education groups had lower prevalence) for tobacco use, hypertension, diabetes, and overweight, whereas in less-urbanized locations, we found such a relationship only for tobacco use and hypertension. This study indicates the growing vulnerability of lower socioeconomic groups to CHD. Preventive strategies to reduce major CHD risk factors should focus on effectively addressing these social disparities.

Socioeconomic status and overweight/obesity in an adult Chinese population in Singapore

BACKGROUND

Studies from industrialized Western countries have reported an inverse association between socioeconomic status and overweight/obesity. In contrast, few studies from newly industrialized countries in Asia have examined this association. In this context, we examined the association between socioeconomic status and overweight/obesity by gender in Chinese adults in Singapore.

METHODS

A population-based cross sectional study of 942 participants (57.3% women, 40-81 years) residing in the Tanjong Pagar district of Singapore was conducted. Education, income, and housing type were used as socioeconomic status indicators. Main outcome-of-interest was the presence of overweight/obesity (n=313), classified by body mass index as overweight (25-29.9 kg/m²), or obese (≥30 kg/m²)

RESULTS

The prevalence of overweight/obesity was 33% in men and 34% in women. In men, SES indicators were not associated with overweight/obesity. In women, SES indicators were found to be inversely associated with overweight/ obesity. Compared to women with secondary/higher education, the odds ratio (OR) (95% confidence interval [CI]) of overweight/obesity in women with primary/lower education was 2.5 (1.5-4.0). Compared to women earning > Singapore dollar (SGD) 1,000 per month, the OR (95% CI) of overweight/obesity among women earning ≤SGD 1,000 was 2.5 (1.4-4.5). Compared to women living in large size public apartments or private houses, the OR (95% CI) of overweight/obesity in women living in small/medium size public apartments was 1.8 (1.2-2.7).

CONCLUSIONS

Lower socioeconomic status, defined by education, income, and housing type was associated with overweight/obesity in Chinese Singaporean women.

Socioeconomic status, access to health care, and outcomes after acute myocardial infarction in Canada's universal health care system

BACKGROUND

There is a debate as to whether universal drug coverage confers similar access to care at all socioeconomic status (SES) levels. Experiences in Canada may bring light to questions raised regarding access.

OBJECTIVE

To assess associations between SES and access to cardiac care and outcomes in Canada's universal health care system.

DESIGN, SETTING, AND PATIENTS

All patients admitted to acute care hospitals in Quebec (QC), Ontario (ON), and British Columbia (BC), between 1996 and either 2000 (QC) or 2001 (ON, BC) with acute myocardial infarction, were identified using provincial government administrative databases (n = 145,882).

MEASUREMENTS

Variables representing SES grouped at the census area level were examined in association with use of cardiac medications and procedures, survival, and readmission, while adjusting for individual-level variables. A Bayesian hierarchical logistic regression model was used to account for the nested structure of the data.

RESULTS

Despite provincial variations in SES and drug reimbursement policies, there were generally no associations between the SES variables and access to cardiac medications or invasive cardiac procedures. The few exceptions were not consistent across SES indicators and/or provinces. Similarly, the only observed effect of SES on clinical outcomes was in BC, where there was increased 1-year mortality among patients living in less-affluent regions (adjusted odds ratios per standard deviation change in proportion of low-income households, 95% Bayesian credible intervals, QC: 1.09, 0.96-1.25; ON: 1.02, 0.95-1.08; and BC: 1.18, 1.09-1.28).

CONCLUSIONS

These results suggest that intermediary factors other than SES, such as cardiovascular risk factors, likely account for observed "wealth-health" gradients in Canada. Implementation of a universal drug coverage policy could decrease socioeconomic disparities in access to health care.

Sociodemographic differences in myocardial infarction risk perceptions among people with coronary heart disease

This study examines sociodemographic differences in myocardial infarction (MI) risk perceptions among people with coronary heart disease (CHD) (N = 3130). Two variables for comparative risk perceptions were computed: (1) own risk compared to that of an average person; and (2) own risk compared to that of an average person with CHD. Comparative optimism in MI risk perceptions was common, particularly among men and those with higher education. CHD severity and psychosocial resources mediated these sociodemographic differences. These results suggest challenges for secondary prevention in CHD, particularly regarding psychosocial interventions for communicating risk information and supporting lifestyle adjustments.

Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: findings from the International Tobacco Control (ITC) Four Country Survey

OBJECTIVE

To examine the effect of socioeconomic status (SES) on nicotine dependence, self-efficacy, and intention to quit.

DESIGN SETTING AND PARTICIPANTS

Data were from the first wave (2002) of the International Tobacco Control (ITC) Four Country Survey (ITC-4), a panel study of over 2000 adult smokers from each of four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews.

MAIN OUTCOME MEASURES

Nicotine dependence, intention to quit, and self-efficacy to quit smoking were the main outcome measures used in this study.

RESULTS

Lower levels of education were associated with higher nicotine dependence. The effect of lower income on higher heaviness of smoking index (HIS) scores was significant in Canada, the UK, and Australia. Respondents with low education had 35% larger odds of low self-efficacy than those with high education. Respondents with low education had 40% larger odds of having no intention to quit than those with high education. Respondents with low income had 23% larger odds of having no intention to quit than those with high income. Country was not a moderator of the association of SES with self-efficacy and intention to quit.

CONCLUSION

To the extent that lower SES smokers are more addicted, they are likely to need more intensive support if they are to be successful in their attempts to quit. Given their lower incomes, this places a special responsibility on government to provide or subsidise such services. This should include access to the widest possible range of effective pharmacotherapies complemented with evidence based counselling and support.

Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 International Tobacco Control (ITC) Four Country Survey

BACKGROUND

Socioeconomic status is strongly associated with smoking prevalence and social class differences contribute substantially to social inequalities in mortality. This research investigated socioeconomic and country variations in smokers' knowledge that smoking causes heart disease, stroke, impotence and lung cancer, that smoke contains cyanide, mercury, arsenic and carbon monoxide, and whether nicotine causes most of the cancer.

METHODS

Data were from the International Tobacco Control (ITC) Four Country Survey, a cohort survey of over 9000 adult smokers from four countries: the United States, Canada, the United Kingdom, and Australia. Data were collected via telephone interviews in 2002.

RESULTS

Higher education and income were associated with higher awareness. For example, the odds of knowing that smoking causes heart disease, stroke and lung cancer were respectively 71%, 34% and 83% larger for respondents with high versus low income. The odds of knowing that smoke contains cyanide, mercury, arsenic and carbon monoxide were respectively 66%, 26%, 44% and 108% larger for respondents with a university degree than those with a high school diploma or lower level of education. Results also revealed that awareness of harms of smoking was generally the highest in Canada and the lowest in the UK.

CONCLUSIONS

Lower socioeconomic status was associated with lower awareness of the harms of smoking and misunderstanding around nicotine. There is a need to improve knowledge of the dangers of smoking among the disadvantaged segments of the population.

Socioeconomic position and twins' health: a life-course analysis of 1266 pairs of middle-aged Danish twins

BACKGROUND

The association between socioeconomic circumstances and health in adulthood could come about through processes that may be divided into factors experienced early in life and those experienced in later adulthood. In order to disentangle the influences on health of the early genetic, prenatal and rearing environmental factors from environmental factor later in life, we compared the health status among male and female twin pairs who lived together during childhood and were discordant or concordant on adult socioeconomic position.

METHODS

A cross-sectional survey among a random sample of middle-aged Danish twins was conducted in 1998-99. The study population included 1266 like-sex twin pairs [52.5% monozygotic (MZ) and 47.6% dizygotic (DZ)]. Data were obtained on childhood and adult social class and on height, BMI, grip strength, depression symptoms, self-rated health, cognitive function, physical activity, smoking, alcohol and food intake.

RESULTS

The expected associations between the individual twins' adult social class and health measures were observed. Among DZ male twins discordant on adult social class, the higher social class twin was on average significantly taller and had higher cognitive test scores. Among DZ female twins discordant on adult social class, the higher social class female twin was more physically active and had a higher cognitive test score. There were no significant health disparities or behavioural differences between the members of MZ twin pairs discordant on adult social class. For most health outcomes, the variability within twin pairs was related to zygosity (higher for DZ than for MZ) but not to social class.

CONCLUSION

This study suggests that the relationship between adult social class and health outcomes in Denmark is due mainly to selection effects rather than a causal effect of social class exposures on health and behaviour.