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Metsä-Simola N, Heggebø K, Kjaer Urhoj S, Martikainen P, Einiö E, Östergren O. Neurological conditions and subsequent divorce risk in the Nordic countries: the importance of gender and both spouses' education. J Epidemiol Community Health 2024:jech-2023-221328. [PMID: 38355292 DOI: 10.1136/jech-2023-221328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Prior studies suggest that poor physical health, accompanied by functional disability, is associated with increased divorce risk. However, this association may depend on gender, the socioeconomic resources of the couple, as well as the social policy and social (in)equality context in which the illness is experienced. This study focuses on neurological conditions, which often have substantial functional consequences. METHODS We used longitudinal population-wide register data from the years 2007-2016 (Denmark, Sweden) or 2008-2017 (Finland, Norway) to follow 2 809 209 married couples aged 30-64 for neurological conditions, identified using information on specialised healthcare for diseases of the nervous system and subsequent divorce. Cox regression models were estimated in each country, and meta-analysis used to calculate across-country estimates. RESULTS During the 10-year follow-up period, 22.2% of couples experienced neurological conditions and 12.0% of marriages ended in divorce. In all countries, divorce risk was elevated among couples where at least one spouse had a neurological condition, and especially so if both spouses were ill. The divorce risk was either larger or similar for husband's illness, compared with wife's illness, in all educational categories. For the countries pooled, the weighted average HR was 1.21 (95% CI 1.20 to 1.23) for wives' illness, 1.27 (95% CI 1.25 to 1.29) for husbands' illness and 1.38 (95% CI 1.34 to 1.42) for couples where both spouses were ill. CONCLUSIONS Despite some variation by educational resources and country context, the results suggest that the social consequences of illness are noticeable even in Nordic welfare states, with the husband's illness being at least as important as the wife's.
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Affiliation(s)
- Niina Metsä-Simola
- Helsinki Instute for Demography and Population Health, University of Helsinki, Helsinki, Finland
- Max Planck - University of Helsinki Center for Social Inequalities in Population Health, Helsinki, Finland
| | | | - Stine Kjaer Urhoj
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark
| | - Pekka Martikainen
- Helsinki Instute for Demography and Population Health, University of Helsinki, Helsinki, Finland
- Max Planck - University of Helsinki Center for Social Inequalities in Population Health, Helsinki, Finland
- Max-Planck-Institute for Demographic Research, Rostock, Germany
| | - Elina Einiö
- Helsinki Instute for Demography and Population Health, University of Helsinki, Helsinki, Finland
- Max Planck - University of Helsinki Center for Social Inequalities in Population Health, Helsinki, Finland
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University & Aging Research Center (ARC), Karolinska Institutet, Stockholm, Sweden
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Altmejd A, Östergren O, Björkegren E, Persson T. Inequality and COVID-19 in Sweden: Relative risks of nine bad life events, by four social gradients, in pandemic vs. prepandemic years. Proc Natl Acad Sci U S A 2023; 120:e2303640120. [PMID: 37943837 PMCID: PMC10655217 DOI: 10.1073/pnas.2303640120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/28/2023] [Indexed: 11/12/2023] Open
Abstract
The COVID-19 pandemic struck societies directly and indirectly, not just challenging population health but disrupting many aspects of life. Different effects of the spreading virus-and the measures to fight it-are reported and discussed in different scientific fora, with hard-to-compare methods and metrics from different traditions. While the pandemic struck some groups more than others, it is difficult to assess the comprehensive impact on social inequalities. This paper gauges social inequalities using individual-level administrative data for Sweden's entire population. We describe and analyze the relative risks for different social groups in four dimensions-gender, education, income, and world region of birth-to experience three types of COVID-19 incidence, as well as six additional negative life outcomes that reflect general health, access to medical care, and economic strain. During the pandemic, the overall population faced severe morbidity and mortality from COVID-19 and saw higher all-cause mortality, income losses and unemployment risks, as well as reduced access to medical care. These burdens fell more heavily on individuals with low income or education and on immigrants. Although these vulnerable groups experienced larger absolute risks of suffering the direct and indirect consequences of the pandemic, the relative risks in pandemic years (2020 and 2021) were conspicuously similar to those in prepandemic years (2016 to 2019).
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Affiliation(s)
- Adam Altmejd
- Swedish Institute for Social Research, Stockholm University, Stockholm106 91, Sweden
- Department of Finance, Stockholm School of Economics, Stockholm106 91, Sweden
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm106 91, Sweden
- Aging Research Center, Karolinska Institutet, Stockholm171 77, Sweden
| | | | - Torsten Persson
- Institute for International Economic Studies, Stockholm University, Stockholm106 91, Sweden
- Suntory and Toyota International Centres for Economics and Related Disciplines, London School of Economics, LondonWC2A 2AE, United Kingdom
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Östergren O, Cederström A, Korhonen K, Martikainen P. Migrant mortality by duration of residence and co-ethnic density - A register-based study on Finnish migrants in Sweden with matched controls in the origin and the destination. Health Place 2023; 83:103064. [PMID: 37348292 DOI: 10.1016/j.healthplace.2023.103064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
Migrant health depends on factors both at the origin and at the destination. Health-related behaviors established before migration may change at the destination. We compare the mortality rates from alcohol- and smoking-related causes and cardiovascular diseases (CVD) of Finnish migrants in Sweden to matched controls in both Sweden and Finland with similar sociodemographic characteristics. Migrant mortality rates from behavioral risk factors lie in-between the rates of non-migrants in the origin and destination. A longer duration of residence is associated with lower mortality and with mortality patterns more similar to Swedes for men. For women, a longer duration of residence is associated with higher mortality, in particular smoking-related mortality, with no tendency of a gradual convergence. The density of Finnish migrants in the local area is modestly associated with mortality. However, CVD mortality tends to be higher and more similar to the level in Finland for migrants in areas with a higher density of Finnish migrants. The results suggest that behavioral changes can reduce mortality differences between migrants and natives and that this can be either beneficial or detrimental to migrant health.
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Affiliation(s)
- Olof Östergren
- Department of Public Health Sciences, Stockholm University, Sweden; Ageing Research Center, Karolinska Institutet, Sweden.
| | | | | | - Pekka Martikainen
- Department of Public Health Sciences, Stockholm University, Sweden; Population Research Unit, University of Helsinki, Finland; Max Planck Institute for Demographic Research, Rostock, Germany
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Gauffin K, Östergren O, Cederström A. Waves of inequality: income differences in intensive care due to Covid-19 in Sweden. Eur J Public Health 2023:ckad094. [PMID: 37322545 PMCID: PMC10393505 DOI: 10.1093/eurpub/ckad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Socioeconomically vulnerable groups were overall more likely to develop severe Covid-19, but specific conditions in terms of preparedness, knowledge and the properties of the virus itself changed during the course of the pandemic. Inequalities in Covid-19 may therefore shift over time. This study examines the relationship between income and intensive care (ICU) episodes due to Covid-19 in Sweden during three distinct waves. METHODS This study uses Swedish register data on the total adult population and estimates the relative risk (RR) of ICU episodes due to Covid-19 by income quartile for each month between March 2020 and May 2022, and for each wave, using Poisson regression analyses. RESULTS The first wave had modest income-related inequalities, while the second wave had a clear income gradient, with the lowest income quartile having an increased risk compared to the high-income group [RR: 1.55 (1.36-1.77)]. In the third wave, the overall need for ICU decreased, but RRs increased, particularly in the lowest income quartile [RR: 3.72 (3.50-3.96)]. Inequalities in the third wave were partly explained by differential vaccination coverage by income quartile, although substantial inequalities remained after adjustment for vaccination status [RR: 2.39 (2.20-2.59)]. CONCLUSIONS The study highlights the importance of considering the changing mechanisms that connect income and health during a novel pandemic. The finding that health inequalities increased as the aetiology of Covid-19 became better understood could be interpreted through the lens of adapted fundamental cause theory.
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Affiliation(s)
- Karl Gauffin
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
- Aging Research Center (ARC), Karolinska Institutet, Solna, Sweden
| | - Agneta Cederström
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
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Östergren O, Rehnberg J, Lundberg O, Miething A. Disruption and selection: the income gradient in mortality among natives and migrants in Sweden. Eur J Public Health 2023:7110224. [PMID: 37023471 DOI: 10.1093/eurpub/ckad051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The income gradient in mortality is generated through an interplay between socio-economic processes and health over the life course. International migration entails the displacement of an individual from one context to another and may disrupt these processes. Furthermore, migrants are a selected group that may adopt distinct strategies and face discrimination in the labour market. These factors may have implications for the income gradient in mortality. We investigate whether the income gradient in mortality differs by migrant status and by individual-level factors surrounding the migration event. METHODS We use administrative register data comprising the total resident population in Sweden aged between 30 and 79 in 2015 (n = 5.7 million) and follow them for mortality during 2015-17. We estimate the income gradient in mortality by migrant status, region of origin, age at migration and country of education using locally estimated scatterplot smoothing and Poisson regression. RESULTS The income gradient in mortality is less steep among migrants compared with natives. This pattern is driven by lower mortality among migrants at lower levels of income. The gradient is less steep among distant migrants than among close migrants, migrants that arrived as adults compared with children and migrants that received their education in Sweden as opposed to abroad. CONCLUSIONS Our results are consistent with the notion that income inequalities in mortality are generated through life-course processes that may be disrupted by migration. Data restrictions prevent us from disentangling life-course disruption from selection into migration, discrimination and labour market strategies.
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Affiliation(s)
- Olof Östergren
- Department of Public Health, Stockholm University, Stockholm, Sweden
- Aging Research Center, Karolinska Institutet, Solna, Sweden
| | - Johan Rehnberg
- Aging Research Center, Karolinska Institutet, Solna, Sweden
| | - Olle Lundberg
- Department of Public Health, Stockholm University, Stockholm, Sweden
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Moustgaard H, Tarkiainen L, Östergren O, Korhonen K, Zengarini N, Costa G, Martikainen P. The contribution of alcohol-related deaths to the life-expectancy gap between people with and without depression - a cross-country comparison. Drug Alcohol Depend 2022; 238:109547. [PMID: 35810620 DOI: 10.1016/j.drugalcdep.2022.109547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Alcohol-related deaths may be among the most important reasons for the shorter life expectancy of people with depression, yet no study has quantified their contribution. We quantify the contribution of alcohol-related deaths to the life-expectancy gap in depression in four European countries with differing levels of alcohol-related mortality. METHODS We used cohort data linking population registers with health-care and death records from Denmark, Finland, Sweden and Turin, Italy, in 1993-2007 (210,412,097 person years, 3046,754 deaths). We identified psychiatric inpatients with depression from hospital discharge registers in Denmark, Finland, and Sweden and outpatients with antidepressant prescriptions from prescription registers in Finland and Turin. We assessed alcohol-related and non-alcohol-related deaths using both underlying and contributory causes of death, stratified by sex, age and depression status. We quantified the contribution of alcohol-related deaths by cause-of-death decomposition of the life-expectancy gap at age 25 between people with and without depression. RESULTS The gap in life expectancy was 13.1-18.6 years between people with and without inpatient treatment for depression and 6.7-9.1 years between those with and without antidepressant treatment. The contribution of alcohol-related deaths to the life-expectancy gap was larger in Denmark (33.6%) and Finland (18.1-30.5%) - i.e., countries with high overall alcohol-related mortality - than in Sweden (11.9%) and Turin (3.2%), and larger among men in all countries. The life-expectancy gap due to other than alcohol-related deaths varied little across countries. CONCLUSIONS Alcohol contributes heavily to the lower life expectancy in depression particularly among men and in countries with high overall alcohol-related mortality.
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Affiliation(s)
- Heta Moustgaard
- Helsinki Institute for Social Sciences and Humanities, University of Helsinki, Vuorikatu 3, 00014, Finland; Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, P.O. Box 18, 00014, Finland.
| | - Lasse Tarkiainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, P.O. Box 18, 00014, Finland; Helsinki Institute for Urban and Regional Studies (URBARIA), University of Helsinki, Yliopistonkatu 3, 00100 Helsinki, Finland.
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, SE - 106 91 Stockholm, Sweden; Aging Research Center, Karolinska Institutet, Tomtebodavägen 18a, SE-171 65 Solna, Sweden.
| | - Kaarina Korhonen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, P.O. Box 18, 00014, Finland.
| | - Nicolás Zengarini
- Epidemiology Unit, Regional Health Service ASL TO3, Via Sabaudia 164, Turin, Grugliasco (TO), Italy.
| | - Giuseppe Costa
- Epidemiology Unit, Regional Health Service ASL TO3, Via Sabaudia 164, Turin, Grugliasco (TO), Italy.
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, P.O. Box 18, 00014, Finland; Department of Public Health Sciences, Stockholm University, SE - 106 91 Stockholm, Sweden; Laboratory of Population Health, Max Planck Institute for Demographic Research, Konrad-Zuse-Str. 1, 18057 Rostock, Germany.
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Östergren O, Fors S, Rehnberg J. Excess Mortality by Individual and Spousal Education for Recent and Long-Term Widowed. J Gerontol B Psychol Sci Soc Sci 2022; 77:946-955. [PMID: 34878543 PMCID: PMC9071383 DOI: 10.1093/geronb/gbab227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES The loss of a spouse is followed by a dramatic but short-lived increase in the mortality risk of the survivor. Contrary to expectations, several studies have found this increase to be larger among those with high education. Having a spouse with high education is associated with lower mortality, which suggests that losing a spouse with high education means the loss of a stronger protective factor than losing a spouse with low education. This may disproportionately affect the high educated because of educational homogamy. METHODS We use Swedish total population registers to construct an open cohort of 1,842,487 married individuals aged 60-89 during 2007-2016, observing 239,276 transitions into widowhood and 277,946 deaths. We use Poisson regression to estimate relative and absolute mortality risks by own and spousal education among the married and recent and long-term widows. RESULTS We find an absolute increase in mortality risk, concentrated to the first 6 months of widowhood across all educational strata. The relative increase in mortality risk is larger in higher educational strata. Losing a spouse with high education is associated with higher excess mortality, which attenuates this difference. DISCUSSION When considering the timing and the absolute level of excess mortality, we find that the overall patterns of excess mortality are similar across educational strata. We argue that widowhood has a dramatic impact on health, regardless of education.
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Affiliation(s)
- Olof Östergren
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Stefan Fors
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Johan Rehnberg
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
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Abstract
OBJECTIVE We investigate recent trends in income inequalities in mortality and the shape of the association in Sweden. We consider all-cause, preventable and non-preventable mortality for three age groups (30-64, 65-79 and 80+ years). DESIGN AND SETTING Repeated cross-sectional design using Swedish total population register data. PARTICIPANTS All persons aged 30 years and older living in Sweden 1995-1996, 2005-2006 and 2016-2017 (n=8 084 620). METHODS Rate differences and rate ratios for all-cause, preventable and non-preventable mortality were calculated per income decile and age group. RESULTS From 1995 to 2017, relative inequalities in mortality by income increased in Sweden in the age groups 30-64 years and 65-79 years. Absolute inequalities increased in the age group 65-79 years. Among persons aged 80+ years, inequalities were small. The shape of the income-mortality association was curvilinear in the age group 30-64 years; the gradient was stronger below the fourth percentile. In the age group 65-79 years, the shape shifted from linear in 1995-1996 to a more curvilinear shape in 2016-2017. In the oldest age group (80+ years), varied shapes were observed. Inequalities were more pronounced in preventable mortality compared with non-preventable mortality. Income inequalities in preventable and non-preventable mortality increased at similar rates between 1995 and 2017. CONCLUSIONS The continued increase of relative (ages 30-79 years) and absolute (ages 65-79 years) mortality inequalities in Sweden should be a primary concern for public health policy. The uniform increase of inequalities in preventable and non-preventable mortality suggests that a more complex explanatory model than only social causation is responsible for increased health inequalities.
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Affiliation(s)
- Johan Rehnberg
- Aging Research Center, Karolinska Institutet/Stockholm University, Stockholm, Sweden
| | - Olof Östergren
- Aging Research Center, Karolinska Institutet/Stockholm University, Stockholm, Sweden
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Stefan Fors
- Aging Research Center, Karolinska Institutet/Stockholm University, Stockholm, Sweden
- Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Johan Fritzell
- Aging Research Center, Karolinska Institutet/Stockholm University, Stockholm, Sweden
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Korhonen K, Moustgaard H, Tarkiainen L, Östergren O, Costa G, Urhoj SK, Martikainen P. Contributions of specific causes of death by age to the shorter life expectancy in depression: a register-based observational study from Denmark, Finland, Sweden and Italy. J Affect Disord 2021; 295:831-838. [PMID: 34706453 DOI: 10.1016/j.jad.2021.08.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/12/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The reasons for the shorter life expectancy of people with depression may vary by age. We quantified the contributions of specific causes of death by age to the life-expectancy gap in four European countries. METHODS Using register-based cohort data, we calculated annual mortality rates in between 1993 and 2007 for psychiatric inpatients with depression identified from hospital-care registers in Denmark, Finland and Sweden, and between 2000 and 2007 for antidepressant-treated outpatients identified from medication registers in Finland and Turin, Italy. We decomposed the life-expectancy gap at age 15 years by age and cause of death. RESULTS The life-expectancy gap was especially large for psychiatric inpatients (12.1 to 21.0 years) but substantial also for antidepressant-treated outpatients (6.3 to 14.2 years). Among psychiatric inpatients, the gap was largely attributable to unnatural deaths below age 55 years. The overall contribution was largest for suicide in Sweden (43 to 45%) and Finland (37 to 40%). In Denmark, 'other diseases' (25 to 34%) and alcohol-attributable causes (10 to 18%) had especially large contributions. Among antidepressant-treated outpatients, largest contributions were observed for suicide (18% for men) and circulatory deaths (23% for women) in Finland, and cancer deaths in Turin (29 to 36%). Natural deaths were concentrated at ages above 65 years. LIMITATIONS The indication of antidepressant prescription could not be ascertained from the medication registers. CONCLUSIONS Interventions should be directed to self-harm and substance use problems among younger psychiatric inpatients and antidepressant-treated young men. Rigorous monitoring and treatment of comorbid somatic conditions and disease risk factors may increase life expectancy for antidepressant-treated outpatients, especially women.
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Affiliation(s)
- Kaarina Korhonen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland, P.O. Box 18, 00014 Helsinki, Finland.
| | - Heta Moustgaard
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland, P.O. Box 18, 00014 Helsinki, Finland; Helsinki Institute of Urban and Regional Studies (URBARIA), University of Helsinki, Helsinki, Finland, Yliopistonkatu 3, 00100 Helsinki, Finland
| | - Lasse Tarkiainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland, P.O. Box 18, 00014 Helsinki, Finland; Helsinki Institute of Urban and Regional Studies (URBARIA), University of Helsinki, Helsinki, Finland, Yliopistonkatu 3, 00100 Helsinki, Finland
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden, SE - 106 91 Stockholm, Sweden; Aging Research Center, Karolinska Institutet, Solna, Sweden, Tomtebodavägen 18a, SE-171 65 Solna, Sweden
| | - Giuseppe Costa
- Epidemiology Unit, Regional Health Service ASL TO3, Turin, Italy, Via Sabaudia 164, Grugliasco (TO), Italy
| | - Stine Kjaer Urhoj
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark, Oster Farimagsgade 5, P.O. Box 2099, 1014 København K, Denmark
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland, P.O. Box 18, 00014 Helsinki, Finland; Department of Public Health Sciences, Stockholm University, Stockholm, Sweden, SE - 106 91 Stockholm, Sweden; Laboratory of Population Health, Max Planck Institute for Demographic Research, Rostock, Germany, Konrad-Zuse-Str. 1, 18057 Rostock, Germany
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Östergren O, Korhonen K, Gustafsson NK, Martikainen P. Home and away: mortality among Finnish-born migrants in Sweden compared to native Swedes and Finns residing in Finland. Eur J Public Health 2021; 31:321-325. [PMID: 33230544 PMCID: PMC8071591 DOI: 10.1093/eurpub/ckaa192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Most first-generation migrants have lower mortality compared to the native population. Finnish-born migrants in Sweden instead have higher mortality; possibly because of health behaviours established before migration. To increase our understanding of this excess mortality, we compared the cause-specific mortality of Finnish migrants in Sweden to both the native population of Sweden and the native Finnish population residing in Finland. Methods We used Swedish and Finnish register data, applying propensity score matching techniques to account for differences in sociodemographic characteristics between the migrants, Swedes and Finns. The index population were Finnish migrants aged 40–60, residing in Sweden in 1995. We compared patterns of all-cause, alcohol- and smoking-related, and cardiovascular disease mortality across the groups in the period 1996–2007. Results Finnish migrant men in Sweden had lower all-cause mortality compared to Finnish men but higher mortality compared to the Swedish men. The same patterns were observed for alcohol-related, smoking-related and cardiovascular disease mortality. Among women, all three groups had similar levels of all-cause mortality. However, Finnish migrant women had higher alcohol-related mortality than Swedish women, similar to Finnish women. Conversely, migrant women had similar levels of smoking-related mortality to Swedish women, lower than Finnish women. Conclusions Finnish-born migrants residing in Sweden have mortality patterns that are typically in between the mortality patterns of the native populations in their country of origin and destination. Both the country of origin and destination need to be considered in order to better understand migrant health.
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Affiliation(s)
- Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.,Aging Research Center, Karolinska Institutet & Stockholm University, Stockholm, Sweden
| | - Kaarina Korhonen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | | | - Pekka Martikainen
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.,Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland.,The Max Planck Institute for Demographic Research, Rostock, Germany
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Brønnum-Hansen H, Östergren O, Tarkiainen L, Hermansen Å, Martikainen P, van der Wel KA, Lundberg O. Changes in life expectancy and lifespan variability by income quartiles in four Nordic countries: a study based on nationwide register data. BMJ Open 2021; 11:e048192. [PMID: 34187828 PMCID: PMC8245444 DOI: 10.1136/bmjopen-2020-048192] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Levels, trends or changes in socioeconomic mortality differentials are typically described in terms of means, for example, life expectancies, but studies have suggested that there also are systematic social disparities in the dispersion around those means, in other words there are inequalities in lifespan variation. This study investigates changes in income inequalities in mean and distributional measures of mortality in Denmark, Finland, Norway, and Sweden over two decades. DESIGN Nationwide register-based study. SETTING The Danish, Finnish, Norwegian and Swedish populations aged 30 years or over in 1997 and 2017. MAIN OUTCOME MEASURES Income-specific changes in life expectancy, lifespan variation and the contribution of 'early' and 'late' deaths to increasing life expectancy. RESULTS Increases in life expectancy has taken place in all four countries, but there are systematic differences across income groups. In general, the largest gains in life expectancy were observed in Denmark, and the smallest increase among low-income women in Sweden and Norway. Overall, life expectancy increased and lifespan variation decreased with increasing income level. These differences grew larger over time. In all countries, a marked postponement of early deaths led to a compression of mortality in the top three income quartiles for both genders. This did not occur for the lowest income quartile. CONCLUSION Increasing life expectancy is typically accompanied by postponement of early deaths and reduction of lifespan inequality in the higher-income groups. However, Nordic welfare societies are challenged by the fact that postponing premature deaths among people in the lowest-income groups is not taking place.
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Affiliation(s)
- Henrik Brønnum-Hansen
- Faculty of Health and Medical Sciences, Department of Public Health, University of Copenhagen, Kobenhavn, Denmark
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Lasse Tarkiainen
- Faculty of Social Sciences, Population Research Unit, University of Helsinki, Helsinki, Finland
| | | | - Pekka Martikainen
- Faculty of Social Sciences, Population Research Unit, University of Helsinki, Helsinki, Finland
| | | | - Olle Lundberg
- Faculty of Social Sciences, Stockholm University, Stockholm, Sweden
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Rehnberg J, Östergren O, Esser I, Lundberg O. Interdependent pathways between socioeconomic position and health: A Swedish longitudinal register-based study. Soc Sci Med 2021; 280:114038. [PMID: 34051557 DOI: 10.1016/j.socscimed.2021.114038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
Health inequalities are generated by the conditions in which people are born, grow, live, work and age. From a life-course perspective, these conditions are formed by complex causal relationships with mutual and intertwined paths between socioeconomic position and health. This study attempts to disentangle some of these processes by examining pathways between socioeconomic position and health across the life-course. We used yearly Swedish national register data with information from over 31 years for two cohorts born 1941-1945 and 1961-1965. We analyzed associations between several indicators of childhood and adult socioeconomic position and health, measured by number of in-patient hospitalizations. We estimated within- and between-person associations using random intercept cross-lagged panel models. The results showed bi-directional associations between socioeconomic position and health that varied in strength across the life-course. Age variations in the associations were primarily observed when individuals aged into or out of age-stratified institutions. In ages where transitions from education to the labor market are common, the associations from health to income and education were strong. Around and after retirement age, the between-person association from health to income was weak, while the association from income to health strengthened. Within-person estimates showed no association between income and subsequent hospitalization among older persons, indicating no direct causal effect of income change on health in this age group. For persons of middle age, the associations were of similar strength in both directions and present at both the between- and within-person level. Our findings highlight the importance of theoretical frameworks and methods that can incorporate the interplay between social, economic, and biological processes over the life-course in order to understand how health inequalities are generated.
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Affiliation(s)
- Johan Rehnberg
- Department of Public Health Sciences, Stockholm University, SE-106 91, Stockholm, Sweden; Aging Research Center, Karolinska Institutet, Solna, SE-171 65, Solna, Sweden.
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, SE-106 91, Stockholm, Sweden; Aging Research Center, Karolinska Institutet, Solna, SE-171 65, Solna, Sweden.
| | - Ingrid Esser
- Department of Public Health Sciences, Stockholm University, SE-106 91, Stockholm, Sweden; Swedish Institute for Social Research, SOFI, Stockholm University, SE-106 91, Stockholm, Sweden.
| | - Olle Lundberg
- Department of Public Health Sciences, Stockholm University, SE-106 91, Stockholm, Sweden.
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13
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Junna LM, Tarkiainen L, Östergren O, Jasilionis D, Martikainen P. Exploring the longevity advantage of doctorates in Finland and Sweden: The role of smoking- and alcohol-related causes of death. Scand J Public Health 2020; 49:419-422. [PMID: 33176584 PMCID: PMC8135231 DOI: 10.1177/1403494820969541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Tobacco smoking and alcohol use contribute to differences in life expectancy between individuals with primary, secondary and tertiary education. Less is known about the contribution of these risk factors to differences at higher levels of education. We estimate the contribution of smoking and alcohol use to the life-expectancy differences between the doctorates and the other tertiary-educated groups in Finland and in Sweden. Methods: We used total population data from Finland and Sweden from 2011 to 2015 to calculate period life expectancies at 40 years of age. We present the results by sex and educational attainment, the latter categorised as doctorate or licentiate degrees, or other tertiary. We also present an age and cause of death decomposition to assess the contribution of deaths related to smoking and alcohol. Results: In Finland, deaths related to smoking and alcohol constituted 48.6% of the 2.1-year difference in life expectancy between men with doctorate degrees and the other tertiary-educated men, and 22.9% of the 2.1-year difference between women, respectively. In Sweden, these causes account for 22.2% of the 1.9-year difference among men, and 55.7% of the 1.6-year difference among women, which in the latter case is mainly due to smoking. Conclusions: Individuals with doctorates tend to live longer than other tertiary-educated individuals. This difference can be partly attributed to alcohol consumption and smoking.
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Affiliation(s)
- Liina M Junna
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Finland.,The Max Planck Institute for Demographic Research, Germany
| | - Lasse Tarkiainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Finland.,Helsinki Institute of Urban and Regional Studies, University of Helsinki, Finland
| | - Olof Östergren
- Department of Public Health Sciences, Stockholm University, Sweden.,Aging Research Centre (ARC), Karolinska Institutet, Sweden
| | - Domantas Jasilionis
- The Max Planck Institute for Demographic Research, Germany.,Demographic Research Centre, Vytautas Magnus University, Lithuania
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Finland.,The Max Planck Institute for Demographic Research, Germany.,Department of Public Health Sciences, Stockholm University, Sweden
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14
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Hossin MZ, Östergren O, Fors S. Is the Association Between Late Life Morbidity and Disability Attenuated Over Time? Exploring the Dynamic Equilibrium of Morbidity Hypothesis. J Gerontol B Psychol Sci Soc Sci 2020; 74:e97-e106. [PMID: 28575329 DOI: 10.1093/geronb/gbx067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/09/2017] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE There is evidence suggesting that the prevalence of disability in late life has declined over time while the prevalence of chronic diseases has increased. The dynamic equilibrium of morbidity hypothesis suggests that these patterns are due to the attenuation of the morbidity-disability link over time. This study aimed to test this assumption empirically. METHODS Data were drawn from three repeated cross-sections of SWEOLD, a nationally representative survey of the Swedish population aged 77 years and older. Poisson regression models were fitted to assess the trends in the prevalence of Activities of Daily Living (ADL) disability, Instrumental ADL (IADL) disability, and selected groups of chronic conditions. The changes in the associations between chronic conditions and disabilities were examined on both multiplicative and additive scales. RESULTS Between 1992 and 2011, the prevalence of both ADL and IADL disabilities decreased whereas the prevalence of nearly all chronic morbidities increased. Significant attenuations of the morbidity-disability associations were found for cardiovascular diseases, metabolic disorders, poor lung function, and psychological distress. DISCUSSION In agreement with the dynamic equilibrium of morbidity hypothesis, this study concludes that the morbidity-disability associations among the Swedish older adults largely waned between 1992 and 2011.
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Affiliation(s)
| | | | - Stefan Fors
- Aging Research Center, Karolinska Institute/Stockholm University, Stockholm, Sweden
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15
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Van Der Wel KA, Östergren O, Lundberg O, Korhonen K, Martikainen P, Andersen AMN, Urhoj SK. A gold mine, but still no Klondike: Nordic register data in health inequalities research. Scand J Public Health 2019; 47:618-630. [PMID: 31291822 PMCID: PMC6745604 DOI: 10.1177/1403494819858046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 11/17/2022]
Abstract
Aims: Future research on health inequality relies on data that cover life-course exposure, different birth cohorts and variation in policy contexts. Nordic register data have long been celebrated as a 'gold mine' for research, and fulfil many of these criteria. However, access to and use of such data are hampered by a number of hurdles and bottlenecks. We present and discuss the experiences of an ongoing Nordic consortium from the process of acquiring register data on socio-economic conditions and health in Denmark, Finland, Norway and Sweden. Methods: We compare experiences of data-acquisition processes from a researcher's perspective in the four countries and discuss the comparability of register data and the modes of collaboration available to researchers, given the prevailing ethical and legal restrictions. Results: The application processes we experienced were time-consuming, and decision structures were often fragmented. We found substantial variation between the countries in terms of processing times, costs and the administrative burden of the researcher. Concerned agencies differed in policy and practice which influenced both how and when data were delivered. These discrepancies present a challenge to comparative research. Conclusions: We conclude that there are few signs of harmonisation, as called for by previous policy documents and research papers. Ethical vetting needs to be centralised both within and between countries in order to improve data access. Institutional factors that seem to facilitate access to register data at the national level include single storage environments for health and social data, simplified ethical vetting and user guidance.
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Affiliation(s)
- Kjetil A. Van Der Wel
- Department of Social Work, Child Welfare
and Social Policy, OsloMet – Oslo Metropolitan University, Norway
| | - Olof Östergren
- Department of Public Health Sciences,
Stockholm University, Sweden
| | - Olle Lundberg
- Department of Public Health Sciences,
Stockholm University, Sweden
| | - Kaarina Korhonen
- Faculty of Social Sciences, Population
Research Unit, University of Helsinki, Finland
| | - Pekka Martikainen
- Faculty of Social Sciences, Population
Research Unit, University of Helsinki, Finland
| | | | - Stine Kjaer Urhoj
- Department of Public Health, Section of
Epidemiology, University of Copenhagen, Denmark
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16
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Östergren O, Martikainen P. The contribution of smoking-related deaths to the gender gap in life expectancy in Sweden between 1997 and 2016. Scand J Public Health 2019; 48:346-349. [PMID: 31068082 DOI: 10.1177/1403494819848278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: In recent decades, smoking-related mortality has declined among men and increased among women in Sweden. We estimate the contribution of smoking-related deaths to the narrowing of the gender gap in life expectancy in Sweden between 1997 and 2016. Methods: We extracted population data on deaths and population under risk on the entire Swedish population aged 25 years and over for the period 1997-2016. Smoking-related mortality was assessed using an indirect method based on lung cancer mortality. We then estimated the contribution of smoking to the gender gap in life expectancy by comparing the observed life expectancies to life expectancies excluding smoking-related deaths. Results: The gender gap in life expectancy was 5.0 years in 1997 and 3.4 years in 2016. The gender gap narrowed by 1.6 years, of which 0.6 years were attributable to smoking-related deaths. Conclusions: The combination of decreasing smoking-related mortality among men and increasing smoking-related mortality among women in Sweden accounted for almost 40% of the narrowing of the gender gap in life expectancy during the period 1997-2016.
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Affiliation(s)
- Olof Östergren
- Department of Public Health Sciences, Stockholm University, Sweden
| | - Pekka Martikainen
- Department of Public Health Sciences, Stockholm University, Sweden.,Population Research Unit, University of Helsinki, Finland
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17
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Östergren O, Martikainen P, Tarkiainen L, Elstad JI, Brønnum-Hansen H. Contribution of smoking and alcohol consumption to income differences in life expectancy: evidence using Danish, Finnish, Norwegian and Swedish register data. J Epidemiol Community Health 2019; 73:334-339. [PMID: 30674585 PMCID: PMC6581103 DOI: 10.1136/jech-2018-211640] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/06/2018] [Accepted: 01/05/2019] [Indexed: 02/06/2023]
Abstract
Background Despite being comparatively egalitarian welfare states, the Nordic countries have not been successful in reducing health inequalities. Previous studies have suggested that smoking and alcohol contribute to this pattern. Few studies have focused on variations in alcohol-related and smoking-related mortality within the Nordic countries. We assess the contribution of smoking and alcohol to differences in life expectancy between countries and between income quintiles within countries. Methods We collected data from registers in Denmark, Finland, Norway and Sweden comprising men and women aged 25–79 years during 1995–2007. Estimations of alcohol-related mortality were based on underlying and contributory causes of death on individual death certificates, and smoking-related mortality was based on an indirect method that used lung cancer mortality as an indicator for the population-level impact of smoking on mortality. Results About 40%–70% of the between-country differences in life expectancy in the Nordic countries can be attributed to smoking and alcohol. Alcohol-related and smoking-related mortality also made substantial contributions to income differences in life expectancy within countries. The magnitude of the contributions were about 30% in Norway, Sweden and among Finnish women to around 50% among Finnish men and in Denmark. Conclusions Smoking and alcohol consumption make substantial contributions to both between-country differences in mortality among the Nordic countries and within-country differences in mortality by income. The size of these contributions vary by country and sex.
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Affiliation(s)
- Olof Östergren
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden, Europe
| | - Pekka Martikainen
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden, Europe.,Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland, Europe.,The Max Planck Institute for Demographic Research, Germany
| | - Lasse Tarkiainen
- Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland, Europe
| | - Jon Ivar Elstad
- NOVA, Centre for Welfare and Labour Research, Oslo Metropolitan University, Oslo, Norway
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18
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Östergren O. Educational inequalities in mortality are larger at low levels of income: A register-based study on premature mortality among 2.3 million Swedes, 2006-2009. SSM Popul Health 2018; 5:122-128. [PMID: 29922712 PMCID: PMC6005813 DOI: 10.1016/j.ssmph.2018.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/02/2018] [Accepted: 05/30/2018] [Indexed: 11/29/2022] Open
Abstract
Education develops skills that help individuals use available material resources more efficiently. When material resources are scarce, each decision becomes comparatively more important. Education may also protect from health-related income decline, since the highly educated tend to work in occupations with lower physical demands. Educational inequalities in health may, therefore, be more pronounced at lower levels of income. The aim of this study is to assess whether the shape of the income gradient in premature mortality depends on the level of education. Total population data on education, income and mortality was obtained by linking several Swedish registers. Income was defined as five-year average disposable household income for ages 35–64 and mortality follow-up covered the period 2006–2009. The final population comprised 2.3 million individuals, 6.2 million person-years and 14,362 deaths. Income was modeled using splines in order to allow variation in the functional form of the association across educational categories. Poisson regression with robust standard errors was used. The curvilinear shape of the association between income and mortality was more pronounced among those with a low education. Both absolute and relative educational inequalities in premature mortality tended to be larger at low levels of income. The greatest income differences in mortality were observed for those with a low education and the smallest for the highly educated. Education and income interact as predictors of mortality. Education is a more important factor for health when access to material resources is limited. Income and education interact as predictors of mortality. Educational inequalities in mortality are larger at low levels of income. Education is negatively associated with mortality at all levels of income.
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Affiliation(s)
- Olof Östergren
- Department of Public Health Sciences, Stockholm University, Sveavägen 160, SE 106 91 Stockholm, Sweden
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19
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Östergren O, Tarkiainen L, Elstad JI, Martikainen P. The contribution of alcohol and smoking to income differences in longevity in the Nordic countries. Eur J Public Health 2017. [DOI: 10.1093/eurpub/ckx187.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- O Östergren
- CHESS, University of Stockholm, Stockholm, Sweden
| | - L Tarkiainen
- CHESS, University of Stockholm, Helsinki, Finland
| | - JI Elstad
- NOVA - Norwegian Social Research, Oslo, Norway
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20
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Affiliation(s)
- P Martikainen
- Population Research Unit, University of Helsinki, Helsinki, Finland
| | - O Östergren
- Centre for Health Equity Studies (CHESS), Karolinska Institutet, Stockholm, Sweden
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21
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Herttua K, Östergren O, Lundberg O, Martikainen P. Influence of affordability of alcohol on educational disparities in alcohol-related mortality in Finland and Sweden: a time series analysis. J Epidemiol Community Health 2017; 71:1168-1176. [PMID: 29061845 DOI: 10.1136/jech-2017-209636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden. METHODS Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988-2007 and in Sweden in 1991-2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol. RESULTS Among Finnish men with secondary education, an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women. CONCLUSIONS Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.
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Affiliation(s)
- Kimmo Herttua
- Department of Public Health, Centre of Maritime Health and Society, University of Southern Denmark, Esbjerg, Denmark.,Department of Social Research, Population Research Unit, University of Helsinki, Helsinki, Finland
| | - Olof Östergren
- Centre for Health Equity Studies, Stockholm University and Karolinska Institutet, Stockholm, Sweden
| | - Olle Lundberg
- Centre for Health Equity Studies, Stockholm University and Karolinska Institutet, Stockholm, Sweden
| | - Pekka Martikainen
- Department of Social Research, Population Research Unit, University of Helsinki, Helsinki, Finland.,Centre for Health Equity Studies, Stockholm University and Karolinska Institutet, Stockholm, Sweden.,The Max Planck Institute for Demographic Research, Rostock, Germany
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22
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Östergren O, Lundberg O, Artnik B, Bopp M, Borrell C, Kalediene R, Leinsalu M, Martikainen P, Regidor E, Rodríguez-Sanz M, de Gelder R, Mackenbach JP. Educational expansion and inequalities in mortality-A fixed-effects analysis using longitudinal data from 18 European populations. PLoS One 2017; 12:e0182526. [PMID: 28832601 PMCID: PMC5568384 DOI: 10.1371/journal.pone.0182526] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/19/2017] [Indexed: 11/19/2022] Open
Abstract
Objective The aim of this paper is to empirically evaluate whether widening educational inequalities in mortality are related to the substantive shifts that have occurred in the educational distribution. Materials and methods Data on education and mortality from 18 European populations across several decades were collected and harmonized as part of the Demetriq project. Using a fixed-effects approach to account for time trends and national variation in mortality, we formally test whether the magnitude of relative inequalities in mortality by education is associated with the gender and age-group specific proportion of high and low educated respectively. Results The results suggest that in populations with larger proportions of high educated and smaller proportions of low educated, the excess mortality among intermediate and low educated is larger, all other things being equal. Conclusion We conclude that the widening educational inequalities in mortality being observed in recent decades may in part be attributed to educational expansion.
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Affiliation(s)
- Olof Östergren
- Centre for Health Equity Studies (CHESS), Stockholm University / Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Olle Lundberg
- Centre for Health Equity Studies (CHESS), Stockholm University / Karolinska Institutet, Stockholm, Sweden
| | - Barbara Artnik
- Department of Public Health, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Carme Borrell
- Agència de Salut Pública de Barcelona, Barcelona, Spain
| | | | - Mall Leinsalu
- Stockholm Centre for Health and Social Change, Södertörn University, Huddinge, Sweden
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | | | - Enrique Regidor
- Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Rianne de Gelder
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johan P. Mackenbach
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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23
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Östergren O, Martikainen P, Lundberg O. The contribution of alcohol consumption and smoking to educational inequalities in life expectancy among Swedish men and women during 1991-2008. Int J Public Health 2017; 63:41-48. [PMID: 28835983 PMCID: PMC5766714 DOI: 10.1007/s00038-017-1029-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 08/06/2017] [Accepted: 08/14/2017] [Indexed: 01/12/2023] Open
Abstract
Objectives To assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden. Methods We used register data on the Swedish population at ages 30–74 during 1991–2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality. Results Alcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking. Conclusions Smoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.
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Affiliation(s)
- Olof Östergren
- Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Sveavägen 160, 106 91, Stockholm, Sweden.
| | - Pekka Martikainen
- Department of Social Research, University of Helsinki, Helsinki, Finland
| | - Olle Lundberg
- Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Sveavägen 160, 106 91, Stockholm, Sweden
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24
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Mackenbach JP, Kulhánová I, Artnik B, Bopp M, Borrell C, Clemens T, Costa G, Dibben C, Kalediene R, Lundberg O, Martikainen P, Menvielle G, Östergren O, Prochorskas R, Rodríguez-Sanz M, Strand BH, Looman CWN, de Gelder R. Changes in mortality inequalities over two decades: register based study of European countries. BMJ 2016; 353:i1732. [PMID: 27067249 PMCID: PMC4827355 DOI: 10.1136/bmj.i1732] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group. DESIGN Register based study. DATA SOURCE Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively). SETTING All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania. RESULTS Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations. CONCLUSIONS Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.
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Affiliation(s)
- Johan P Mackenbach
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Ivana Kulhánová
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Barbara Artnik
- Department of Public Health, Faculty of Medicine, Ljubljana, Slovenia
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Switzerland
| | - Carme Borrell
- Agència de Salut Pública de Barcelona, Barcelona, Spain
| | - Tom Clemens
- School of Geosciences, University of Edinburgh, Edinburgh
| | - Giuseppe Costa
- Department of Clinical Medicine and Biology, University of Turin, Italy
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh
| | | | - Olle Lundberg
- Center for Health Equity Studies, Stockholm, Sweden Department of Health Sciences, Mid Sweden University, Östersund
| | | | - Gwenn Menvielle
- Sorbonne Universités, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | | | | | | | - Bjørn Heine Strand
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Caspar W N Looman
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Rianne de Gelder
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
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25
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Östergren O. Growing gaps: The importance of income and family for educational inequalities in mortality among Swedish men and women 1990–2009. Scand J Public Health 2015; 43:563-70. [DOI: 10.1177/1403494815585401] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2015] [Indexed: 11/16/2022]
Abstract
Aims: Although absolute levels of mortality have decreased among Swedish men and women in recent decades, educational inequalities in mortality have increased, especially among women. The aim of this study is to disentangle the role of income and family type in educational inequalities in mortality in Sweden during 1990–2009, focusing on gender differences. Methods: Data on individuals born in Sweden between the ages of 30 and 74 years were collected from total population registries, covering a total of 529,275 deaths and 729 million person-months. Temporary life expectancies (age 30–74 years) by education were calculated using life tables, and rate ratios were estimated with Poisson regression with robust standard errors. Results: Temporary life expectancy improved among all groups except low educated women. Relative educational inequalities in mortality (RRs) increased from 1.79 to 1.98 among men and from 1.78 to 2.10 among women. Variation in family type explained some of the inequalities among men, but not among women, and did not contribute to the trend. Variation in income explained a larger part of the educational inequalities among men compared to women and also explained the increase in educational inequalities in mortality among men and women. Conclusions: Increasing educational inequalities in mortality in Sweden may be attributed to the increase in income inequalities in mortality.
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Affiliation(s)
- Olof Östergren
- Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Sweden
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Mackenbach JP, Kulhánová I, Menvielle G, Bopp M, Borrell C, Costa G, Deboosere P, Esnaola S, Kalediene R, Kovacs K, Leinsalu M, Martikainen P, Regidor E, Rodriguez-Sanz M, Strand BH, Hoffmann R, Eikemo TA, Östergren O, Lundberg O. Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries. J Epidemiol Community Health 2014; 69:207-17; discussion 205-6. [DOI: 10.1136/jech-2014-204319] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Mackenbach JP, Kulhánová I, Bopp M, Deboosere P, Eikemo TA, Hoffmann R, Kulik MC, Leinsalu M, Martikainen P, Menvielle G, Regidor E, Wojtyniak B, Östergren O, Lundberg O. Variations in the relation between education and cause-specific mortality in 19 European populations: a test of the "fundamental causes" theory of social inequalities in health. Soc Sci Med 2014; 127:51-62. [PMID: 24932917 DOI: 10.1016/j.socscimed.2014.05.021] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/06/2014] [Accepted: 05/14/2014] [Indexed: 12/28/2022]
Abstract
Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a "fundamental cause" which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities. We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30-79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable. Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education-mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large. In conclusion, our results provide some further support for the theory of "fundamental causes". However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.
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Affiliation(s)
- Johan P Mackenbach
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands.
| | - Ivana Kulhánová
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Matthias Bopp
- Institute of Social and Preventive Medicine, University of Zurich, Switzerland
| | | | - Terje A Eikemo
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands; Department of Sociology and Political Science, NTNU, Trondheim, Norway
| | - Rasmus Hoffmann
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Margarete C Kulik
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA, Rotterdam, Netherlands
| | - Mall Leinsalu
- Stockholm Centre on Health of Societies in Transition, Södertörn University, Huddinge, Sweden; Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | | | - Gwenn Menvielle
- INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, Paris, France
| | - Enrique Regidor
- Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Spain
| | - Bogdan Wojtyniak
- Department of Monitoring and Analyses of Population Health, National Institute of Public Health-National Institute of Hygiene, Warsaw, Poland
| | | | - Olle Lundberg
- Center for Health Equity Studies, Stockholm, Sweden; Department of Health Sciences, Mid Sweden University, Östersund, Sweden
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Kulik MC, Menvielle G, Eikemo TA, Bopp M, Jasilionis D, Kulhánová I, Leinsalu M, Martikainen P, Östergren O, Mackenbach JP. Educational inequalities in three smoking-related causes of death in 18 European populations. Nicotine Tob Res 2013; 16:507-18. [PMID: 24212763 DOI: 10.1093/ntr/ntt175] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Smoking is an important determinant of socioeconomic inequalities in mortality in many countries. As the smoking epidemic progresses, updates on the development of mortality inequalities attributable to smoking are needed. We provide estimates of relative and absolute educational inequalities in mortality from lung cancer, aerodigestive cancers, and chronic obstructive pulmonary disease (COPD)/asthma in Europe and assess the contribution of these smoking-related diseases to inequalities in all-cause mortality. METHODS We use data from 18 European populations covering the time period 1998-2007. We present age-adjusted mortality rates, relative indices of inequality, and slope indices of inequality. We also calculate the contribution of inequalities in smoking-related mortality to inequalities in overall mortality. RESULTS Among men, relative inequalities in mortality from the 3 smoking-related causes of death combined are largest in the Czech Republic and Hungary and smallest in Spain, Sweden, and Denmark. Among women, these inequalities are largest in Scotland and Norway and smallest in Italy and Spain. They are often larger among men and tend to be larger for COPD/asthma than for lung and aerodigestive cancers. Relative inequalities in mortality from these conditions are often larger in younger age groups, particularly among women, suggesting a possible further widening of inequalities in mortality in the coming decades. The combined contribution of these diseases to inequality in all-cause mortality varies between 13% and 32% among men and between -5% and 30% among women. CONCLUSION Our results underline the continuing need for tobacco control policies, which take into account socioeconomic position.
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Affiliation(s)
- Margarete C Kulik
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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