Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990–2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.     

The Contribution of Smoking to Black-White Differences in U.S. Mortality

Smoking has significantly impacted American mortality and remains a major cause of morbidity and mortality. No previous study has systematically examined the contribution of smoking-attributable deaths to mortality trends among blacks or to black-white mortality differences at older ages over time in the United States. In this article, we employ multiple methods and data sources to provide a comprehensive assessment of this contribution. We find that smoking has contributed to the black-white gap in life expectancy at age 50 for males, accounting for 20 % to 48 % of the gap between 1980 and 2005, but not for females. The fraction of deaths attributable to smoking at ages above 50 is greater for black males than for white males; and among men, current smoking status explains about 20 % of the black excess relative risk in all-cause mortality at ages above 50 without adjustment for socioeconomic characteristics. These findings advance our understanding of the contribution of smoking to contemporary mortality trends and differences and reinforce the need for interventions that better address the needs of all groups.     

Understanding the age and cause drivers of recent longevity trends in Australia

Longevity continues to increase in Australia. The period 1979–2011 saw increases in life expectancy at birth of 6.9 years to 84.7 years for females, and 9.5 years to 80.2 years for males. A decomposition analysis reveals that the majority of the increase, particularly for females, is attributable to mortality improvement at older ages, and that gains are being made at increasingly older ages over time. Improvements in circulatory disease mortality account for a very significant component of life expectancy gains over the period—75 % for females and 60 % for males—with land transport accidents, congenital and perinatal mortality, and neoplasms also making significant positive contributions. Dementia and Alzheimer’s disease, and lung neoplasms for females, have had a negative impact. Females currently outlive males by 4.5 years on average, with ischaemic heart disease and prostate and other neoplasms the important positive contributors to this differential, and breast cancer having a negative effect. With 93 % of females and 88 % of males now surviving to age 65 in Australia, continued life expectancy improvements will depend to a large extent on success in delaying death at the older ages.     

Losses of Expected Lifetime in the United States and Other Developed Countries: Methods and Empirical Analyses

Patterns of diversity in age at death are examined using e ^†, a dispersion measure that equals the average expected lifetime lost at death. We apply two methods for decomposing differences in e ^†. The first method estimates the contributions of average levels of mortality and mortality age structures. The second (and newly developed) method returns components produced by differences between age- and cause-specific mortality rates. The United States is close to England and Wales in mean life expectancy but has higher life expectancy losses and lacks mortality compression. The difference is determined by mortality age structures, whereas the role of mortality levels is minor. This is related to excess mortality at ages under 65 from various causes in the United States. Regression on 17 country-series suggests that e ^† correlates with income inequality across countries but not across time. This result can be attributed to dissimilarity between the age- and cause-of-death structures of temporal mortality reduction and intercountry mortality variation. It also suggests that factors affecting overall mortality decrease differ from those responsible for excess lifetime losses in the United States compared with other countries. The latter can be related to weaknesses of health system and other factors resulting in premature death from heart diseases, amenable causes, accidents and violence.     

Including the Smoking Epidemic in Internationally Coherent Mortality Projections

We present a new mortality projection methodology that distinguishes smoking- and non-smoking-related mortality and takes into account mortality trends of the opposite sex and in other countries. We evaluate to what extent future projections of life expectancy at birth (e ₀) for the Netherlands up to 2040 are affected by the application of these components. All-cause mortality and non-smoking-related mortality for the years 1970–2006 are projected by the Lee-Carter and Li-Lee methodologies. Smoking-related mortality is projected according to assumptions on future smoking-attributable mortality. Projecting all-cause mortality in the Netherlands, using the Lee-Carter model, leads to high gains in e ₀ (4.1 for males; 4.4 for females) and divergence between the sexes. Coherent projections, which include the mortality experience of the other 21 sex- and country-specific populations, result in much higher gains for males (6.4) and females (5.7), and convergence. The separate projection of smoking and non-smoking-related mortality produces a steady increase in e ₀ for males (4.8) and a nonlinear trend for females, with lower gains in e ₀ in the short run, resulting in temporary sex convergence. The latter effect is also found in coherent projections. Our methodology provides more robust projections, especially thanks to the distinction between smoking- and non-smoking-related mortality.     

Living and dying in the U.S.A.: Sociodemographic determinants of death among blacks and whites

This paper examines the demographic and social factors associated with differences in length of life by race. The results demonstrate that sociodemographic factors--age, sex, marital status, family size, and income--profoundly affect black and white mortality. Indeed, the racial gap in overall mortality could close completely with increased standards of living and improved lifestyles. Moreover, examining cause-specific mortality while adjusting for social factors shows that compared to whites, blacks have a lower mortality risk from respiratory diseases, accidents, and suicide; the same risk from circulatory diseases and cancer; and higher risks from infectious diseases, homicide, and diabetes. These results underscore the importance of examining social characteristics to understand more clearly the race differences in overall and cause-specific mortality.     

Mortality and economic fluctuations

Using wavelet methods, this paper analyzes the relationship between the age-adjusted, infant, and cause-specific mortality rates and the business cycle in Sweden over the period 1800–2000 (1911–1996 for cause-specific mortality). For the period 1800–2000, an increase in GDP by 1% decreased mortality by 0.7%. This overall relationship is due to a strong counter-cyclical relationship in the nineteenth century, which disappeared in the twentieth century. In contrast, in the twentieth century higher mortality in economic upturns is found for mortality caused by circulatory diseases (including stroke) and accidents.     

Mortality attributable to obesity among middle-aged adults in the united states

Obesity is considered a major cause of premature mortality and a potential threat to the longstanding secular decline in mortality in the United States. We measure relative and attributable risks associated with obesity among middle-aged adults using data from the Health and Retirement Study (1992–2004). Although class II/III obesity (BMI _ 35.0 kg/m2) increases mortality by 40% in females and 62% in males compared with normal BMI (BMI = 18.5-24.9), class I obesity (BMI = 30.0-34.9) and being overweight (BMI = 25.0-29.9) are not associated with excess mortality. With respect to attributable mortality, class II/III obesity (BMI _ 35.0) is responsible for approximately 4% of deaths among females and 3% of deaths among males. Obesity is often compared with cigarette smoking as a major source of avoidable mortality. Smoking-attributable mortality is much larger in this cohort: about 36% in females and 50% in males. Results are robust to confounding by preexisting diseases, multiple dimensions of socioeconomic status (SES), smoking, and other correlates. These findings challenge the viewpoint that obesity will stem the long-term secular decline in U.S. mortality.     

The impact of early-life economic conditionson cause-specific mortality during adulthood

The aim of this study is to assess the effects of economic conditions in early life on cause-specific mortality during adulthood. The analyses are performed on a unique historical sample of 14,520 Dutch individuals born in 1880–1918, who are followed throughout life. The economic conditions in early life are characterized using cyclical variations in annual real per capital gross domestic product during pregnancy and the first year of life. Exposure to recessions in early life appears to significantly increase cancer mortality risks of older males and females. It also significantly increases other mortality risks especially for older females. The residual life expectancies are up to about 8 and 6 % lower for male and female cancer mortality, respectively, and up to about 5 % lower for female cardiovascular mortality. Our analyses show that cardiovascular and cancer mortality risks are related and that not taking this association into account leads to biased inference.     

The effect of number of siblings on adult mortality: Evidence from Swedish registers for cohorts born between 1938 and 1972

Demographic research has paid much attention to the impact of childhood conditions on adult mortality. We focus on one of the key aspects of early life conditions, sibling group size, and examine the causal effect of growing up in a large family on mortality. While previous studies have focused on low- or middle-income countries, we examine whether growing up in a large family is a disadvantage in Sweden, a context where most parents have adequate resources, which are complemented by a generous welfare state. We used Swedish register data and frailty models, examining all-cause and cause-specific mortality between the ages of 40 and 74 for the 1938–72 cohorts, and also a quasi-experimental approach that exploited multiple births as a source of exogenous variation in the number of siblings. Overall our results do not indicate that growing up in a large family has a detrimental effect on longevity in Sweden.     

US mortality in an international context: age variations

Compared to other developed countries, the United States ranks poorly in terms of life expectancy at age 50. We seek to shed light on the US's low life expectancy ranking by comparing the age-specific death rates of 18 developed countries at older ages. A striking pattern emerges: between ages 40 and 75, US all-cause mortality rates are among the poorest in the set of comparison countries. The US position improves dramatically after age 75 for both males and females. We consider four possible explanations of the age patterns revealed by this analysis: (1) access to health insurance; (2) international differences in patterns of smoking; (3) age patterns of health care system performance; and (4) selection processes. We find that health insurance and smoking are not plausible sources of this age pattern. While we cannot rule out selection, we present suggestive evidence that an unusually vigorous deployment of life-saving technologies by the US health care system at very old ages is contributing to the age-pattern of US mortality rankings. Differences in obesity distributions are likely to be making a moderate contribution to the pattern but uncertainty about the risks associated with obesity prevents a precise assessment.     

Latin American convergence and divergence towards the mortality profiles of developed countries

It is uncertain whether Latin America and Caribbean (LAC) countries are approaching a single mortality regime. Over the last three decades, LAC has experienced major public health interventions and the highest number of homicides in the world. However, these interventions and homicide rates are not evenly shared across countries. This study documents trends in life expectancy and lifespan variability for 20 LAC countries, 2000–14. By extending a previous method, we decompose differences in lifespan variability between LAC and a developed world benchmark into cause-specific effects. For both sexes, dispersion of amenable diseases through the age span makes the largest contribution to the gap between LAC and the benchmark. Additionally, for males, the concentration of homicides, accidents, and suicides in mid-life further impedes mortality convergence. Great disparity exists in the region: while some countries are rapidly approaching the developed regime, others remain far behind and suffer a clear disadvantage in population health.     

Education,cognitive ability,and cause-specific mortality: A structural approach

Education is negatively associated with most major causes of death. Prior work ignores the premise that cause-specific hazards are interdependent and that both education and mortality depend on cognitive ability. We analyse Swedish men aged 18–63, focusing on months lost due to specific causes—which solves the interdependence problem—and use a structural model that accounts for confounding due to cognitive ability. In a standard Cox model controlling for Intelligence Quotient, improving education is associated with large decreases in mortality for major causes of death. In the structural model, improving education is associated with a small decrease in months lost for most causes and education levels. Among the least educated, however, improving education strongly reduces the months lost, mainly those lost from external causes, such as accidents and suicide. Results suggest that conventional analysis of education and mortality may be biased, even if accounting for observed cognition.     

Effect of aggregation on the estimation of trend in mortality

"There are three approaches to analyzing and forecasting age-specific mortality: (1) analyze age-specific data directly, (2) analyze each cause-specific mortality series separately and add the results, (3) analyze cause-specific mortality series jointly and add the results. We show that if linear models are used for cause-specific mortality, then the three approaches often give close results even when cause-specific series are correlated. This result holds for cross-correlations arising from random misclassification of deaths by cause, and also for certain patterns of systematic misclassification....The results are illustrated with U.S. age-specific mortality: (1) analyse age-specific mortality data from 1968-1985. In some cases the aggregate forecasts appear to be the more credible ones." This is a revised version of a paper originally presented at the 1990 Annual Meeting of the Population Association of America (see Population Index, Vol. 56, No. 3, Fall 1990, p. 407).     

Lifetime risk of pregnancy-related death among Zambian women: district-level estimates from the 2010 census

The aim of this study was to examine district differentials in the lifetime risk of pregnancy-related death among females aged 15–49 in Zambia. We used data on household deaths collected in the 2010 census to estimate the lifetime risk of pregnancy-related death among females in Zambia. Using all-cause age-specific death rates, we generated female life tables for 74 districts and estimated person-years of exposure to all-cause mortality at each age. We then applied age-specific pregnancy-related mortality rates to the person-years of exposure to obtain estimates of adult lifetime risk that took account of competing causes of death. We used the ArcGIS software to analyse clustering and the spatial distribution of risk. A female aged 15 in Zambia had a 3.7 % chance of dying a pregnancy-related death before the age of 50. At district level, the lifetime risk ranged from 1.7 to 7.7 %. The Global Moran’s I was 0.452 (z-score 5.8, p value <0.01), indicating clustering of districts with similar risk levels of pregnancy-related mortality. Clustering of high-risk districts was found in Western province while clustering of low risk districts was found in Lusaka and Muchinga provinces. The level of adult lifetime risk was more positively associated with pregnancy-related mortality than with fertility. Females in Zambia have a high lifetime risk of pregnancy-related death overall but this risk varies greatly across the different districts of the country. The observed diversity is larger than when merely studying differences between provinces and is only weakly linked to differences in fertility levels. The identification of districts with varying levels of risk should enable evidence-based and focused delivery of maternal health services in districts where risk of death from maternal causes is greatest.     

Incarcerating death: Mortality in U.S. state correctional facilities, 1985–1998

Using data from the U.S. Bureau of Justice Statistics and Census Bureau, I estimate death rates of working-age prisoners and nonprisoners by sex and race. Incarceration was more detrimental to females in comparison to their male counterparts in the period covered by this study. White male prisoners had higher death rates than white males who were not in prison. Black male prisoners, however, consistently exhibited lower death rates than black male nonprisoners did. Additionally, the findings indicate that while the relative difference in mortality levels of white and black males was quite high outside of prison, it essentially disappeared in prison. Notably, removing deaths caused by firearms and motor vehicles in the nonprison population accounted for some of the mortality differential between black prisoners and nonprisoners. The death rates of the other groups analyzed suggest that prison is an unhealthy environment; yet, prison appears to be a healthier place than the typical environment of the nonincarcerated black male population. These findings suggest that firearms and motor vehicle accidents do not sufficiently explain the higher death rates of black males, and they indicate that a lack of basic healthcare may be implicated in the death rates of black males not incarcerated.     

The choice among past trends as a basis for the prediction of future trends in old-age mortality

We explored the extent to which projections of future old-age mortality trends differ when different projection bases are used. For seven European countries, four alternative sets of annual rates of mortality change were estimated with age-period log-linear regression models, and subsequently applied to age-specific all-cause mortality rates (80+) in 1999 to predict mortality levels up to 2050. On average, up to 2050, e80 is predicted to increase further by 2.33 years among men and 4.03 years among women. Choosing a historical period of 25 instead of 50 years results in higher predicted gains in e80 for men but lower gains for women. Choosing non-smoking-related mortality instead of all-cause mortality leads to higher gains for women and mixed results for men. In all alternatives there is a strong divergence of predicted mortality levels between the countries. Future projections should be preceded by a thorough study of past trends and their determinants.     

The choice among past trends as a basis for the prediction of future trends in old-age mortality

We explored the extent to which projections of future old-age mortality trends differ when different projection bases are used. For seven European countries, four alternative sets of annual rates of mortality change were estimated with age–period log-linear regression models, and subsequently applied to age-specific all-cause mortality rates (80+) in 1999 to predict mortality levels up to 2050. On average, up to 2050, e80 is predicted to increase further by 2.33 years among men and 4.03 years among women. Choosing a historical period of 25 instead of 50 years results in higher predicted gains in e80 for men but lower gains for women. Choosing non-smoking-related mortality instead of all-cause mortality leads to higher gains for women and mixed results for men. In all alternatives there is a strong divergence of predicted mortality levels between the countries. Future projections should be preceded by a thorough study of past trends and their determinants.     

Ethnic and Birth Weight Differences in Cause-Specific Infant Mortality

This article examines ethnic differences in cause-specific infant mortality, using linked birth and infant death records from a cohort of New Mexican singleton infants, 1980-1983. The research, which applies log-linear analysis, focuses on the combined influences of ethnicity, birth weight, maternal age, and plurality on birth outcomes--that is, on infant survival and deaths due to perinatal, congenital, and respiratory diseases and to sudden infant death syndrome. The results confirm the pronounced impact of birth weight on infant mortality and identify similarities and differences among Anglo, Hispanic, and American Indian babies with respect to cause-specific infant mortality.     

The education effect on population health: a reassessment

Demographic research frequently reports consistent and significant associations between formal educational attainment and a range of health risks such as smoking, drug abuse, and accidents, as well as the contraction of many diseases, and health outcomes such as mortality—almost all indicating the same conclusion: better-educated individuals are healthier and live longer. Despite the substantial reporting of a robust education effect, there is inadequate appreciation of its independent influence and role as a causal agent. To address the effect of education on health in general, three contributions are provided: 1) a macro-level summary of the dimensions of the worldwide educational revolution and a reassessment of its causal role in the health of individuals and in the demographic health transition are carried out; 2) a meta-analysis of methodologically sophisticated studies of the effect of educational attainment on all-cause mortality is conducted to establish the independence and robustness of the education effect on health; and 3) a schooling-cognition hypothesis about the influence of education as a powerful determinant of health is developed in light of new multidisciplinary cognitive research.