Effects of Local Health Interventions on Inequality in Life Expectancy: New Publicly Available Data

Using Regulatory Stances to See All the Commercial Determinants of Health

Policy Points The commercial determinants of health (CDoH) concept, which currently focuses on markets that harm health, should be expanded to refer to the interface between commerce and health, which can sometimes have positive public health consequences. The regulatory stances framework helps us classify public health preferences for regulating specific markets related to CDoH, based on the intended effects of regulations on market size. The regulatory stances a jurisdiction can adopt can be classified as ranging from prohibitionist through contractionist, permissive, and expansionist, to universalist. The regulatory stances framework increases the usefulness of the CDoH concept by expanding the conversation beyond negative determinants of health and providing a fuller view of the tools at the disposal of society to alter markets and improve health.

CONTEXT

The effects of commerce on the public health are omnipresent. The commercial determinants of health (CDoH) represent a burgeoning area of scholarly debate and activist policymaking to redress markets that adversely affect public health. The CDoH debate is a logical extension of the tobacco control movement, but, to its detriment, the CDoH conversation remains primarily focused policies and proposals that are analogous to historical tobacco control strategies.

METHODS

This paper argues that for the CDoH to develop further and broaden its appeal, it should expand to cover markets with conditional and positive impacts on health. To explain and order this conversation, a comparative framework for regulatory policy is introduced: the regulatory stances. The regulatory stances classify a regulatory policy based on the intended effect of policy on the size of a market in the future relative to the present.

FINDINGS

Some markets that interface between commerce and health do not inherently harm health. Regulatory policy toward these markets should be different in intent than regulatory policy for markets with negative health effects.

CONCLUSIONS

By using the regulatory stances framework to encompass markets that have positive or conditional effects on health as well as those that have adverse health effects, the CDoH conversation can shift away from the exclusive focus on strategies to shrink markets with adverse health impacts to consider a wider array of policy options.

Economic influences on population health in the United States: Toward policymaking driven by data and evidence

Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.

Association of Social Mobility With the Income-Related Longevity Gap in the United States: A Cross-Sectional, County-Level Study

IMPORTANCE

Despite substantial research, the drivers of the widening gap in life expectancy between rich and poor individuals in the United States-known as the longevity gap-remain unknown. The hypothesis of this study is that social mobility may play an important role in explaining the longevity gap.

OBJECTIVE

To assess whether social mobility is associated with income-related differences in life expectancy in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, ecological study used data from 1559 counties in the United States to assess the association of social mobility with average life expectancy at age 40 years by sex and income quartile among adult men and women over the period of January 2000 through December 2014. Bayesian generalized linear multilevel regression models were used to estimate the association, with adjustment for a range of socioeconomic, demographic, and health care system characteristics.

EXPOSURES

County-level social mobility, here operationalized as the association of the income rank of individuals born during the period of January 1980 through December 1982 (based on tax record data, averaged over the period January 2010 through December 2012) with the income ranks of their parents (averaged over the period January 1996 through December 2000) using the location where the parent first claimed the child as a dependent at age 15 years to identify counties.

MAIN OUTCOMES AND MEASURES

The main outcome was life expectancy at age 40 years by sex and income quartile.

RESULTS

The sample consisted of 1559 counties, which represented 93% of the US population in 2000. Each 1-SD increase in social mobility-equivalent to the difference between a low-mobility state, such as Alabama (ranked 49th on this measure), and a higher-mobility state, such as Massachusetts (ranked 23rd on this measure)-was associated with a 0.38-year (95% credible interval [CrI], 0.29-0.47) and a 0.29-year (95% CrI, 0.21-0.38) increase in county-level life expectancy among men and women, respectively, in the lowest income quartile. Estimates for life expectancies among county residents in the highest income quartile were smaller in magnitude and not robust to covariate adjustment (men: 0.10-year [95% CrI, -0.02 to 0.22] increase; women: 0.08-year [95% CrI, -0.05 to 0.20] increase). Increasing social mobility in all counties to the value of the highest social mobility county was associated with decreases in the life expectancy gap between the highest and lowest income quartiles by 1.4 (95% CrI, 0.7-2.1) years for men and 1.1 (95% CrI, 0.5-1.6) years for women nationally, representing a 20% decrease.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, higher county-level social mobility was associated with smaller county-level gaps in life expectancy by income. These findings motivate further investigation of causal relationships between policies that shift social mobility and health outcomes.

Estimating the long-run relationship between state cigarette taxes and county life expectancy

INTRODUCTION

While a large body of literature suggests that tobacco control legislation-including fiscal measures such as excise taxes-effectively reduces tobacco smoking, the long-run (10+ years) relationship between cigarettes excise taxes and life expectancy has not been directly evaluated. Here, we test the hypothesis that increases in state cigarette excise taxes are positively associated with long-run increases in population-level life expectancy.

METHODS

We studied age-standardised life expectancy among all US counties from 1996 to 2012 by sex, in relation to state cigarette excise tax rates by year, controlling for other demographic, socioeconomic and county-specific features. We used an error-correction model to assess the long-run relationship between taxes and life expectancy. We additionally examine whether the relationship between cigarette taxes and life expectancy was mediated by changes to county smoking prevalence and varied by the sex, income and rural/urban composition of a county.

RESULTS

For every one-dollar increase in cigarette tax per pack (in 2016 dollars), county life expectancy increased by 1 year (95% CI 0.60 to 1.40 years) over the long run, with the first 6-month increase in life expectancy taking 10 years to materialise. The association was mediated by changes in smoking prevalence and the magnitude of the association steadily increased as county income decreased.

CONCLUSIONS

Results suggest that increasing cigarette excise tax rates translates to consequential population-level improvements in life expectancy, with larger effects in low-income counties.