Cancer mortality patterns among Turkish immigrants in four European countries and in Turkey

The aim of this study on cancer mortality among Turkish immigrants, for the first time, traditional comparisons in migrant health research have been extended simultaneously in two ways. First, comparisons were made to cancer mortality from the immigrants’ country of origin and second, cancer mortality among Turkish immigrants across four host countries (Belgium, Denmark, France and the Netherlands) was compared. Population-based cancer mortality data from these countries were included. Age-standardized mortality rates were computed for the local-born and Turkish population of each country. Relative differences in cancer mortality were examined by fitting country-specific Poisson regression models. Globocan data on cancer mortality in Turkey from 2008 were used in order to compare mortality rates of Turkish immigrants with those from their country of origin. Turkish immigrants had lower all-cancer mortality than the local-born populations of their host countries, and mortality levels comparable to all-cancer mortality rates in Turkey. In the Netherlands and France breast cancer mortality was consistently lower in Turkish immigrants women than among local-born women. Lung cancer mortality was slightly lower in Turkish immigrants in the Netherlands and France but varied considerably between migrants in these two host countries. Stomach cancer mortality was significantly higher in Turkish immigrants when compared to local-born French and Dutch. Our findings indicate that exposures both in the country of origin and in the host country can have an effect on the cancer mortality of immigrants. Despite limitations affecting any cross-country comparison of mortality, the innovative multi-comparison approach is a promising way to gain further insights into determinants of trends in cancer mortality of immigrants.     

Socioeconomic inequalities in mortality within ethnic groups in the Netherlands, 1995-2000

STUDY OBJECTIVE: To analyse socioeconomic inequalities in mortality in Dutch, Turkish, Moroccans, Surinamese, and Antillean/Aruban men and women living in the Netherlands and to assess the contribution of specific causes of death to these inequalities. DESIGN: Open cohort design using data from the Municipal Population Registers and cause of death registry. SETTING: the Netherlands from 1995 through 2000. PARTICIPANTS: All inhabitants of the Netherlands. MAIN OUTCOME MEASURES: This study calculated directly standardised mortality rates by mean neighbourhood income and estimated relative mortality ratios comparing the two lowest socioeconomic groups with the two highest socioeconomic groups for all and cause specific mortality by country of origin and sex. MAIN RESULTS: Socioeconomic differences in total mortality were comparatively large in Dutch, (RR = 1.49, CI = 1.46 to 1.52), Surinamese (1.32, 1.19 to 1.46), and Antillean/Aruban men (1.56, 1.29 to 1.89) and in Dutch (1.39, 135 to 1.42) and Surinamese women (1.27, 1.11 to 1.46). They were comparatively small among Turkish (1.10, 0.99 to 1.23) and Moroccan men (1.10, 0.97 to 1.26) and among Turkish (1.13, 0.97 to 1.33), Moroccan (1.12, 0.93 to 1.35) and Antillean/Aruban women (1.03, 0.80 to 1.33). The mortality differences among the Dutch were partly attributable to inequalities in mortality from cardiovascular diseases, whereas among Antillean/Aruban men external causes strongly contributed to the mortality differences. The small differences among Turkish and Moroccan men were due to a lack of inequalities for cardiovascular diseases and small inequalities for the other causes. CONCLUSIONS: The impact of socioeconomic status on mortality differed between ethnic groups living in the Netherlands. Maintaining small socioeconomic inequalities in mortality among Turkish and Moroccans men and women and among Antillean/Aruban women could prevent future increases in overall mortality in these groups.     

Tobacco-related mortality following the Peto-Lopez epidemiological model used in international public health comparison

In estimating the overall scale of death from tobacco in developed countries, there is a range of uncertainty between the lower limits and the upper limits of what is scientifically plausible. Following a method by Peto, Lopez et al. to base the calculations chiefly on the lower limits, we have compared the tobacco-related mortality for females and males separately in various ages groups between Poland and Sweden over a period of three decades. This method is built on the following steps: ignore deaths under age 35, ignore cirrhosis and non-medical causes, compare lung cancer at ages 35-79 with US non-smokers and concerning other diseases at ages 35-79 make a conservative halving of apparent excess attributed to tobacco. Concerning mortality all causes a tobacco-related mortality among Polish men has increased more than 50% from the 5-year period 1965-1969 to the period 1990-1994. The analyse for women gives a strongly other picture compared with men showing much lower rates. When comparing the middle age group with the overall population it is interesting to find a faster increase in tobacco-related mortality rates for Polish men and for Swedish women in the age group 45-64 years than in the overall group. Swedish men have reduced their smoking habit strongly and far more than Polish men (17 and 42% respectively 1999). Concerning the pattern of tobacco use it is obvious that Swedish and Polish women during the last descades have had the same and slowly decreasing smoking prevalence (21 and 23% respectively 1999). It is important to use not only lung cancer mortality but a total picture of tobacco-related disorders as indicators of the success in tobacco control in a country as well for women as for men, especially in the middle age groups.     

Influence of individual and neighbourhood socioeconomic status on mortality among black,Mexican-American,and white women and men in the United States

STUDY OBJECTIVE:s: This study examines the influence of individual and neighbourhood socioeconomic status (SES) on mortality among black, Mexican-American, and white women and men in the US. The authors had three study objectives. Firstly, they examined mortality rates by both individual level SES (measured by income, education, and occupational/employment status) and neighbourhood level SES (index of neighbourhood income/wealth, educational attainment, occupational status, and employment status). Secondly, they examined whether neighbourhood SES was associated with mortality after controlling for individual SES. Thirdly, they calculated the population attributable risk to estimate the reduction in mortality rates if all women and men lived in the highest SES neighbourhoods. DESIGN: National Health Interview Survey (1987-1994), linked with 1990 census tract (neighbourhood proxy) and mortality data through 1997. SETTING/PARTICIPANTS: Nationally representative sample of 59 935 black, 19 201 Mexican-American, and 344 432 white men and women (six gender and racial/ethnic groups), aged 25-64 at interview. MAIN RESULTS: Mortality rates for all six gender and racial/ethnic groups were two to four times higher for those with the lowest incomes (lowest quartile) who lived in the lowest SES neighbourhoods (lowest tertile) compared with those with the highest incomes who lived in the highest SES neighbourhoods. For the six groups, the age adjusted mortality risk associated with living in the lowest SES neighbourhoods ranged from 1.43 to 1.61. The mortality risk decreased but remained significant (p values <.05) after adjusting for each of the three individual measures of SES, with the exception of Mexican-American women. Furthermore, the mortality risk associated with living in the lowest SES neighbourhoods remained significant after simultaneously adjusting for all three individual measures of SES for white men (p<0.001) and white women (p<0.05). Deaths would hypothetically be reduced by about 20% for each subgroup if everyone had the same death rates as those living in the highest SES neighbourhoods (highest tertile). CONCLUSIONS: Living in a low SES neighbourhood confers additional mortality risk beyond individual SES.     

Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study

This longitudinal study evaluates the role of individual and contextual socioeconomic determinants in the socioeconomic inequalities in incidence and mortality for coronary events in Turin, Italy, using hierarchical models. All residents aged 35-74 at the start of 1997 were included in the study population. We considered as outcomes all incident cases and deaths that occurred in the study population in the period 1997-2002. The socioeconomic indicators were educational level, job status and median income per census tract. A neighbourhood deprivation index was also used, which combines, in an aggregated measure, a series of poor individual socioeconomic conditions. The analyses were performed using hierarchical Poisson models, with individuals (n = 523,755) considered as level I units and neighbourhoods (n = 23) as level II units. Among men, we observed an inverse gradient in incidence by educational level and an excess risk for persons who were not actively employed. More marked excesses were found for mortality (RR: 1.63; 95% CI: 1.05-2.55, for unemployed persons compared to employed persons). Among women, greater socioeconomic differences were observed for both incidence and mortality; all of the individual indicators contributed to these differences. The differentials in mortality were particularly great for the retired and for housewives (RR: 1.98; 95% CI: 1.40-2.81). Slight excesses in incidence were observed among men for the most deprived areas. The results of this study reveal that job status is the most important individual factor explaining socioeconomic inequalities for coronary events, whereas context seems to play a marginal role.     

Mortality among non-western migrants in The Netherlands

Mortality among 10 groups of non-western migrants to The Netherlands, observed in the period 1995-2000, is compared with mortality among people who were born in and whose parents were born in The Netherlands. The migrant groups concerned consisted of people who were born in, or whose parents were born in Turkey, Morocco, Surinam, The Netherlands Antilles, Ghana, Somalia, Iraq, Iran, Afghanistan and Vietnam. Differences in mortality were adjusted for age, marital status, region, degree of urbanization, and socioeconomic status. Despite the fact that most migrants originate from countries with a substantially higher mortality rate than The Netherlands, most groups had similar or more favourable total mortality rates than native Dutch people. Men from Turkey and Surinam had slightly elevated mortality rates and men and women from Somalia had a notably higher mortality rate than native Dutch people. The generally favourable mortality rates among migrants are the result of two compensating phenomena: higher mortality among young migrants than among young native Dutch people, and lower mortality among elderly migrants than among elderly native Dutch people. An analysis of cause-of-death patterns revealed relatively low mortality from cardiovascular diseases, cancer and respiratory diseases in most migrant groups, and relatively high mortality from infectious diseases and injuries. These findings are unlikely to have been influenced by incomplete registration of mortality. Selective migration may play a role--some migrant groups have a relatively high level of education for example. Also some of the findings may be explained by a difference in timing between the health benefits and the health risks of migration. Migrant health could be benefiting from the favourable socioeconomic, public health and health-care conditions in The Netherlands, but not yet be affected by the higher risks of cancer and cardiovascular disease associated with prosperity.     

Inequalities in mortality among refugees and immigrants compared to native Danes -- a historical prospective cohort study

ABSTRACT: BACKGROUND: Comparisons of mortality patterns between different migrant groups, and between migrants and natives, are relevant to understanding, and ultimately reducing, inequalities in health. To date, European studies on migrants' mortality patterns are scarce and are based solely on country of birth, rather than migrant status. However, mortality patterns may be affected by implications in relation to migrant status, such as health hazards related to life circumstances before and during migration, and factors related to ethnic origin. Consequently, we investigated differences in both all-cause and cause-specific mortality from cancer and cardiovascular disease among refugees and immigrants, compared with the mortality among native Danes. METHODS: A register-based, historical prospective cohort design. All refugees (n = 29,139) and family-reunited immigrants (n = 27,134) who, between 1 January1993 and 31 December1999, were granted right of residence in Denmark were included and matched 1:4 on age and sex with native Danes. To identify deaths, civil registration numbers were cross-linked to the Register of Causes of Death (01.01.1994--31.12.2007) and the Danish Civil Registration System (01.01.1994--31.12.2008). Mortality rate ratios were estimated separately for men and women by migrant status and region of birth, adjusting for age and income and using a Cox regression model, after a median follow-up of 10--13 years after arrival. RESULTS: Compared with native Danes, all-cause mortality was significantly lower among female (RR = 0.78; 95%CI: 0.71;0.85) and male (RR = 0.64; 95%CI: 0.59-0.69;) refugees. The rates were also significantly lower for immigrants: women (RR = 0.44; 95%CI: 0.38;0.51) and men (RR = 0.43; 95%CI: 0.37;0.51). Both migrant groups also had lower cause-specific mortality from cancer and cardiovascular diseases. For both all-cause and cause-specific mortality, immigrants generally had lower mortality than refugees, and differences were observed according to ethnic origin. CONCLUSIONS: Mortality patterns were overall advantageous for refugees and immigrants compared with native Danes. Research should concentrate on disentangling the reasons behind migrants' health advantages, in order to enlighten future preventive public-health efforts, for the benefit of the entire population.     

Social inequalities in the associations between urban green spaces,self-perceived health and mortality in Brussels: Results from a census-based cohort study

This study examines the associations between residential urban green spaces (UGS) and self-perceived health and natural cause mortality, applying an intersectional approach across gender, education and migrant background. We used data from the 2001 Belgian census linked to register data on emigration and mortality for the period 2001–2014, including 571,558 individuals aged 16–80 residing in Brussels (80% response rate). Residential UGS were assessed with the Normalized Difference Vegetation Index (NDVI) within a 300 m buffer from the residential address and perceived neighbourhood greenness. Multilevel logistic and Cox proportional hazards regression models were conducted to estimate associations between UGS and poor self-perceived health at baseline and natural cause mortality during follow-up. Residential UGS were inversely associated with both outcomes, but there were differences between groups. The strongest beneficial associations among women were found in the lower educated, regardless of their migrant background. For men the strongest association was found in those with tertiary education and Belgian origin. No significant beneficial associations were found in men originating from low and middle-income countries. Applying an intersectionality approach is crucial to understand health inequalities related to UGS exposure. Further research in different geographical contexts is needed to contrast our findings.     

Duration of residence was not consistently related to immigrant mortality

OBJECTIVE: This paper aimed to examine immigrant mortality according to duration of residence in the Netherlands and to compare duration-specific mortality levels to levels of mortality in the native Dutch population. STUDY DESIGN AND SETTING: For the years 1995-2000, we linked the national cause of death register, that contains information on deaths of legal residents, to the municipal population register, that contains information on all legal residents. We studied mortality in relation to period of immigration by means of directly standardized mortality rates and Poisson regression. RESULTS: All cause mortality was not related to year of immigration among Turkish and Moroccan men and women, and among Surinamese women. Among Surinamese men and among Antilleans/Aruban men and women, mortality was higher in more recent immigrants. Part of their excess mortality was due to their relatively low socioeconomic status. For most specific causes of death, no consistent relation with duration of residence was observed. CONCLUSION: A consistent relation between duration of residence and immigrant mortality was only observed in some immigrant groups. The results suggest that the healthy migrant effect or adaptation of health-related behaviors were no predominant determinants of immigrant mortality in the Netherlands.     

Inequalities in Frailty Among Older Turkish and Moroccan Immigrants and Native Dutch: Data from the Longitudinal Aging Study Amsterdam

Very few studies have investigated frailty among older immigrants in Europe. The aim of the current study was to investigate inequalities in frailty in young-olds related to gender, educational level and country of origin, as well as intersections between these characteristics. Cross-sectional data were used from older Turkish and Moroccan immigrants (n?=?466) and native Dutch (n?=?1,020), all aged 55–65 years and participating in the Longitudinal Aging Study Amsterdam. Frailty was assessed with a 30-item frailty index, based on the deficit accumulation approach. Frailty was higher among women, lower educated, and people with a migration background. Of all groups considered, frailty levels were the highest among Turkish immigrants. No statistically significant interaction effects between gender, educational level and country of origin were found. When targeting frailty interventions, special attention should be devoted to older immigrants, as they are the most vulnerable group with the highest frailty levels.

     

Ethnic variations in mortality in pre-school children in Denmark, 1973–2004

The objective of the study was to describe ethnic differences in under-five-years mortality in Denmark according to maternal country of origin. We conducted a large registry-linkage study of all singleton live-born children from mothers born in Denmark and from the ten largest migrant groups (n = 1,841,450). Study outcomes were death before the age of 5 years from all causes combined and the most frequent death causes. Results showed that children of mothers of Turkish, Pakistani, Somali and Iraqi origin had an elevated risk of dying before the age of five compared to offspring of mothers born in Denmark, with hazards ratios and 95% confidence intervals of 1.48 (1.31–1.67), 1.97 (1.68–2.32), 1.70 (1.29–2.25), and 1.92 (1.41–2.62), respectively. Ethnic differences were also observed in the underlying causes of death. Children of mothers born in Former Yugoslavia, Lebanon, Norway, Sweden, Iran, and Afghanistan did not differ in under-five-years mortality from ethnic Danish children. Adjustments for household income did not attenuate the risk estimates. In conclusion, we found excess child mortality in some migrant groups, but not in all. The differences could not be explained by socioeconomic status.     

Breastfeeding Practices in Relation to Country of Origin Among Women Living in Denmark: A Population-Based Study

The objective of this study was to describe breastfeeding practices and to compare the risk of suboptimal breastfeeding of women living in Denmark according to country of origin, and further to examine how socio-economic position and duration of stay in the country affected this risk. Information on breastfeeding of 42,420 infants born 2002–2009 and living in eighteen selected Danish municipalities was collected from the Danish Health Visitor’s Child Health Database. The data was linked with data on maternal socio-demographic information from Danish population-covering registries. Suboptimal breastfeeding was defined as <4 months of full breastfeeding as described by the Danish Health and Medicines Authority. We used logistic regression to model the crude associations between suboptimal breastfeeding and country of origin, and taking maternal age and parity, and a variety of parental socio-economic measures into account. Suboptimal breastfeeding was more frequent among non-Western migrant women than among women of Danish origin. Women who were descendants of Turkish and Pakistani immigrants had a higher risk of suboptimal breastfeeding as compared to the group of women who had migrated from the same countries, suggesting that acculturation did not favor breastfeeding. For all but the group of women who had migrated from Pakistan, adjustment for socio-demographic indicators (age, parity, education, attachment to labour market, and income) eliminated the increased risk of suboptimal breastfeeding. There was no evidence for differences in the breastfeeding support provided at hospital level according to migrant status. Suboptimal breastfeeding was more frequent among women who were non-Nordic migrants and descendants of migrants than among women with Danish origin.     

Individual and community-level effects in the socioeconomic inequalities of AIDS-related mortality in an urban area of southern Europe

OBJECTIVE: To study socioeconomic inequalities in AIDS mortality in Barcelona, Spain, during the periods 1991-6 (before highly active antiretroviral therapy (HAART)) and 1997-2001 (post-HAART) taking into account individual as well as community effects of socioeconomic level. DESIGN: Cross-sectional design. SETTING: Barcelona, Spain. PARTICIPANTS: All residents aged > or =20 years. All AIDS-related deaths occurring between 1991 and 2001 were studied. The individual variables analysed were age, sex, educational level, neighbourhood of residence and HIV transmission group. Male unemployment was used as the community-level indicator of neighbourhood deprivation. Multilevel Poisson regression models were fitted to estimate the relationship between AIDS mortality and the individual- and community-level variables. RESULTS: At the individual level, AIDS mortality relative risks (RR) were higher among intravenous drug users (IDUs) with lower educational level in both periods. For the younger population, the RR of AIDS-related mortality associated with having little education compared with having a primary education or more was 4.7 (95% CI 3.6 to 6.1) in men and 5.2 (95%CI 3.6 to 7.7) in women in the pre-HAART period, and 4.7 (95% CI 2.7 to 8.1) in men and 4.5 (95% CI 1.4 to 14.1) in women in the post-HAART period. At the community level, an area effect in AIDS mortality was found, which was more important in neighbourhoods having high deprivation in both periods, although the effect was most important in the post-HAART period. CONCLUSIONS: This study has shown inequalities in AIDS mortality in terms of both individual variables and a community-level variable in the pre-HAART as well as in the post-HAART period. These socioeconomic inequalities of AIDS mortality must be considered when prevention and treatment strategies are implemented.     

Social differences in the burden of long-standing illness in Denmark

Summary. Objectives To estimate the impact of diseases on social differences in life expectancy and expected lifetime with illness among Danes in 1995–99. Methods Expected lifetime with and without long-standing illness were calculated for groups with low, medium and high educational levels. Estimates based on observed rates of mortality and prevalence of illness were compared with those based on rates from which a specific disease had been eliminated. Results Partial life expectancy (age 30–75) would increase by almost 1.5 years if cancer were eliminated. Expected lifetime without long-standing illness would increase by approximately 1 year. Elimination of cardiovascular diseases would increase partial life expectancy, mainly among men with a low educational level. If diseases of the musculoskeletal system were eliminated the benefit would be greatest for persons with a low educational level. Conclusions The gain in life expectancy to be expected by eliminating certain diseases decreased with educational level. Elimination of cancer would extend lifetime both with and without illness for all educational levels. Submitted: 27 June 2005; Accepted: 7 March 2006     

Healthy and unhealthy migrant effect on the mortality of immigrants from wealthy countries residing in Spain

This study attempts to identify the possible existence of a healthy migrant effect and an unhealthy migrant effect on the mortality of immigrants from wealthy countries who move to Spain. Immigrants aged 35–64 years from France, Germany, Great Britain and 16 other wealthy OECD countries who resided in Spain were compared with respect to: (1) mortality from cancer, cardiovascular disease, and all other diseases and (2) employment status, duration of residence, and educational level, in two geographic areas: the “preferred destination area”—the Mediterranean coast, Balearic Islands and Canary Islands—and the rest of Spain. In general, cancer mortality was lower and mortality from cardiovascular disease was higher in immigrants who resided in the preferred destination area than in their countries of origin and than in immigrants who resided in the rest of Spain. Immigrants in the preferred destination area had a higher percentage of retired persons, longer time of residence and a lower percentage of persons with university education. The largest differences between the two areas in cardiovascular and all-disease mortality and in the frequency of the aforementioned sociodemographic characteristics were observed in British immigrants and those from the 16 OECD countries. Possible explanations for these findings are suggested which are compatible with the presence of an unhealthy and/or healthy immigrant bias in the two areas.     

Cardiovascular mortality patterns in Turkey: what is the evidence?

In Turkey, reliable cause-specific mortality data are not available. It is thus unknown whether ischaemic heart disease (as in western Europe and the US) or stroke (as in the Far East) is the prevailing cause of cardiovascular death. This information, however, is required for planning cardiovascular prevention programmes. We analyse available Turkish national cause-of-death data as well as patterns of cardiovascular mortality in a hospital in Ankara and among Turkish migrants in Germany. According to national statistics, the ischaemic heart disease-to-stroke ratio would be 0.3 among men aged 45-64 years, lower than that in Japan. Hospital and migrant data show this ratio to be 2-4. We demonstrate the implausibility of the national data by assessing the precision of cause-of-death assignment. We then discuss to what degree mortality experience among migrants is representative for their country of origin. Our findings suggest that the pattern of cardiovascular mortality in Turkey is closer to that in western Europe and the US than to that in the Far East. Finally, we discuss options for improving cardiovascular surveillance in Turkey.     

The role of individual and contextual socioeconomic circumstances on mortality: analysis of time variations in a city of north west Italy

STUDY OBJECTIVE: To evaluate the independent and mutual effects of neighbourhood deprivation and of individual socioeconomic conditions on mortality and to assess the trends over the past 30 years and the residual neighbourhood heterogeneity. DESIGN: General and cause specific mortality was analysed as a function of time period, highest educational level achieved, housing conditions, and neighbourhood deprivation, using multilevel Poisson models stratified by gender and age class. SETTING: The study was conducted in Turin, a city in north west Italy with nearly one million inhabitants and consisting of 23 neighbourhoods. PARTICIPANTS: The study population included three cohorts of persons aged 15 years or older, recorded in the censuses of 1971, 1981, and 1991 and followed up for 10 years after each census. MAIN RESULTS: Individual and contextual socioeconomic conditions showed an independent and significant impact on mortality, both among men and women, with significantly higher risks for coronary heart and respiratory diseases among people, aged less than 65 years, residing in deprived neighbourhoods (9% and 15% excess for coronary heart diseases, 20% and 24% for respiratory diseases, respectively for men and women living in deprived neighbourhoods compared with rich). The decreasing time trend in general mortality was less pronounced among men with lower education and poorer housing conditions, compared with their more advantaged counterparts; the same was found in less educated women aged less than 65 years. CONCLUSIONS: These results and further developments in the evaluation of impact and mechanisms of other contextual effects can provide information for both health and non-health oriented urban policies.     

Cardiovascular mortality patterns in Turkey: What is the evidence?

In Turkey, reliable cause-specific mortality data are not available. It is thus unknown whether ischaemic heart disease (as in western Europe and the US) or stroke (as in the Far East) is the prevailing cause of cardiovascular death. This information, however, is required for planning cardiovascular prevention programmes. We analyse available Turkish national cause-of-death data as well as patterns of cardiovascular mortality in a hospital in Ankara and among Turkish migrants in Germany. According to national statistics, the ischaemic heart disease-to-stroke ratio would be 0.3 among men aged 45–64 years, lower than that in Japan. Hospital and migrant data show this ratio to be 2–4. We demonstrate the implausibility of the national data by assessing the precision of cause-of-death assignment. We then discuss to what degree mortality experience among migrants is representative for their country of origin. Our findings suggest that the pattern of cardiovascular mortality in Turkey is closer to that in western Europe and the US than to that in the Far East. Finally, we discuss options for improving cardiovascular surveillance in Turkey.     

Widening socioeconomic inequalities in mortality in six Western European countries

OBJECTIVES: During the past decades a widening of the relative gap in death rates between upper and lower socioeconomic groups has been reported for several European countries. Although differential mortality decline for cardiovascular diseases has been suggested as an important contributory factor, it is not known what its quantitative contribution was, and to what extent other causes of death have contributed to the widening gap in total mortality. METHODS: We collected data on mortality by educational level and occupational class among men and women from national longitudinal studies in Finland, Sweden, Norway, Denmark, England/Wales, and Italy (Turin), and analysed age-standardized death rates in two recent time periods (1981-1985 and 1991-1995), both total mortality and by cause of death. For simplicity, we report on inequalities in mortality between two broad socioeconomic groups (high and low educational level, non-manual and manual occupations). RESULTS: Relative inequalities in total mortality have increased in all six countries, but absolute differences in total mortality were fairly stable, with the exception of Finland where an increase occurred. In most countries, mortality from cardiovascular diseases declined proportionally faster in the upper socioeconomic groups. The exception is Italy (Turin) where the reverse occurred. In all countries with the exception of Italy (Turin), changes in cardiovascular disease mortality contributed about half of the widening relative gap for total mortality. Other causes also made important contributions to the widening gap in total mortality. For these causes, widening inequalities were sometimes due to increasing mortality rates in the lower socioeconomic groups. We found rising rates of mortality from lung cancer, breast cancer, respiratory disease, gastrointestinal disease, and injuries among men and/or women in lower socioeconomic groups in several countries. CONCLUSIONS: Reducing socioeconomic inequalities in mortality in Western Europe critically depends upon speeding up mortality declines from cardiovascular diseases in lower socioeconomic groups, and countering mortality increases from several other causes of death in lower socioeconomic groups.     

Acculturation and tobacco use among Chinese Americans

OBJECTIVES: We examined the relationship between acculturation and tobacco use behaviors among Chinese Americans. METHODS: Using a Chinese-language instrument based on validated questions from several national surveys, we conducted in-person, household-based interviews with 712 representative adults aged 18-74 years. RESULTS: Observed smoking prevalence was 29% for men and 4% for women. Predictors of smoking cessation included being 35 years and older and having a high level of tobacco-related knowledge. Acculturation was positively associated with a history of never smoking, as was being younger than 35 years and having a high level of tobacco-related knowledge. CONCLUSIONS: Acculturation was positively associated with never smoking among men but not with smoking cessation. However, knowledge of tobacco-related health risks was associated with both. Results indicate a need for language-specific educational interventions.