The turn of the gradient? Educational differences in breast cancer mortality in 18 European populations during the 2000s.

This study aims to investigate the association between educational level and breast cancer mortality in Europe in the 2000s. Unlike most other causes of death, breast cancer mortality tends to be positively related to education, with higher educated women showing higher mortality rates. Research has however shown that the association is changing from being positive over non-existent to negative in some countries. To investigate these patterns, data from national mortality registers and censuses were collected and harmonized for 18 European populations. The study population included all women aged 30-74. Age-standardized mortality rates, mortality rate ratios, and slope and relative indexes of inequality were computed by education. The population was stratified according to age (women aged 30-49 and women aged 50-74). The relation between educational level and breast cancer mortality was predominantly negative in women aged 30-49, mortality rates being lower among highly educated women and higher among low educated women, although few outcomes were statistically significant. Among women aged 50-74, the association was mostly positive and statistically significant in some populations. A comparison with earlier research in the 1990s revealed a changing pattern of breast cancer mortality. Positive educational differences that used to be significant in the 1990s were no longer significant in the 2000s, indicating that inequalities have decreased or disappeared. This evolution is in line with the "fundamental causes" theory which stipulates that whenever medical insights and treatment become available to combat a disease, a negative association with socio-economic position will arise, independently of the underlying risk factors.

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004.

BACKGROUND: Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990-1994 and 2000-2004 in 14 European countries. METHODS: We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990-1994 and 2000-2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method. RESULTS: In 2000-2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between -1% and 56% among women. Since 1990-1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women. CONCLUSIONS: In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

Heavy smoking and lung cancer: are women at higher risk? Result of the ICARE study.

BACKGROUND: Whether women are more or equally susceptible to the carcinogenic effects of cigarette smoke on the lungs compared with men is a matter of controversy. Using a large French population-based case-control study, we compared the lung cancer risk associated with cigarette smoking by gender. METHODS: The study included 2276 male and 650 female cases and 2780 male and 775 female controls. Lifetime smoking exposure was represented by the comprehensive smoking index (CSI), which combines the duration, intensity and time since cessation of smoking habits. The analysis was conducted among the ever smokers. All of the models were adjusted for age, department (a regional administrative unit), education and occupational exposures. RESULTS: Overall, we found that the lung cancer risk was similar among men and women. However, we found that women had a two-fold greater risk associated with a one-unit increase in CSI than men of developing either small cell carcinoma (OR=15.9, 95% confidence interval (95% CI) 7.6, 33.3 and 6.6, 95% CI 5.1, 8.5, respectively; P<0.05) or squamous cell carcinoma (OR=13.1, 95% CI 6.3, 27.3 and 6.1, 95% CI 5.0, 7.3, respectively; P<0.05). The association was similar between men and women for adenocarcinoma. CONCLUSION: Our findings suggest that heavy smoking might confer to women a higher risk of lung cancer as compared with men.

Measuring social inequalities in cause-specific mortality in France: comparison between linked and unlinked approaches.

BACKGROUND: Monitoring the time trends in socioeconomic inequalities in mortality by cause is a key public health issue. The aim of this study was to compare methods to measure social inequalities in cause-specific mortality in the French population aged 25-55 years. More specifically, it compares bias and precision related to the use of occupational class declared at the last census (linked data) to the one declared at the time of death on the death certificate (unlinked data). METHODS: We used a representative sample of 1% of the French population. Causes of death were obtained by direct linkage with the French national death registry. Occupational class was classified into eight categories. Taking professionals and managers as the reference, relative risks of mortality by cause and their 95% confidence intervals were estimated using Poisson models for the 1983-1989, 1991-1997, and 2000-2006 periods. The relative risks were calculated with both linked data and exhaustive unlinked data. RESULTS: Over the 2000-2006 period, occupational classes declared at census and on the death certificate were consistent for half of the deaths. Relative risks for manual workers were found to be similar between the two approaches over the 1983-1989 and 1991-1997 periods, and higher for the unlinked approach over the 2000-2006 period. Over the latter period, the order and magnitude of relative risks varied similarly by occupational class and cause of death for both approaches. Confidence intervals obtained from linked data were wide. CONCLUSION: Occupational class derived from the death certificate must be used with caution as a measure for epidemiological purposes and the available linked data do not allow accurate estimates of social inequalities in cause-specific mortality. Other solutions should be considered in order to improve the follow-up of social inequalities in mortality. This would require the collection of educational level on the death certificate or the linkage of the cause of death database with other exhaustive and informative databases.

Educational inequalities in tuberculosis mortality in sixteen European populations.

OBJECTIVE: To describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries. DESIGN: Data were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities. RESULTS: The number of TB deaths reported was 8530, with a death rate of 3 per 100 000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations. CONCLUSIONS: Socio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

Prevalence of educational inequalities in obesity between 1970 and 2003 in France.

This paper examines trends in obesity rates and education-related absolute and relative inequalities in obesity over the last 40 years in France. Data are drawn from the French Decennial Health Surveys of 1970, 1980, 1991 and 2003. The difference in obesity rates between the least- and most-educated, the Slope Index of Inequality, is used to estimate absolute inequalities in obesity. The ratio of the corresponding rates, the Relative Index of Inequality, reveals the relative inequalities in obesity. Obesity rates were similar in men and women, but educational inequalities were greater in women. Obesity rates were similar over the first three surveys but increased for all in the 2003 survey. This increase was accompanied by increases in absolute inequalities in men (P = 0.04) from a Slope Index of Inequality of 4.80% (95% confidence interval [CI] = 2.27, 7.32) to 8.64% (95% CI = 5.97, 11.32) and women (P = 0.004) from 8.90% (95% CI = 6.18, 11.63) to 14.57% (95% CI = 11.83, 17.32). Relative inequalities in obesity remained stable over the 40 years. Recent increase in obesity rates in France is accompanied by increases in absolute education-related inequalities, while relative inequalities have remained stable; this suggests that obesity rates have increased at a much faster rate in the low-education groups.

Social inequalities in mortality by cause among men and women in France.

BACKGROUND: The aim of this study was to compare inequalities in mortality (all causes and by cause) by occupational group and educational level between men and women living in France in the 1990s. METHODS: Data were analysed from a permanent demographic sample currently including about one million people. The French Institute of Statistics (INSEE) follows the subjects and collects demographic, social and occupational information from the census schedules and vital status forms. Causes of death were obtained from the national file of the French Institute of Health and Medical Research (INSERM). A relative index of inequality (RII) was calculated to quantify inequalities as a function of educational level and occupational group. Overall all-cause mortality, mortality due to cancer, mortality due to cardiovascular disease and mortality due to external causes (accident, suicide, violence) were considered. RESULTS: Overall, social inequalities were found to be wider among men than among women, for all-cause mortality, cancer mortality and external-cause mortality. However, this trend was not observed for cardiovascular mortality, for which the social inequalities were greater for women than for men, particularly for mortality due to ischaemic cardiac diseases. CONCLUSIONS: This study provides evidence for persistent social inequalities in mortality in France, in both men and women. These findings highlight the need for greater attention to social determinants of health. The reduction of cardiovascular disease mortality in low educational level groups should be treated as a major public health priority.

Educational differences in cancer mortality among women and men: a gender pattern that differs across Europe.

We used longitudinal mortality data sets for the 1990s to compare socioeconomic inequalities in total cancer mortality between women and men aged 30-74 in 12 different European populations (Madrid, Basque region, Barcelona, Slovenia, Turin, Switzerland, France, Belgium, Denmark, Norway, Sweden, Finland) and to investigate which cancer sites explain the differences found. We measured socioeconomic status using educational level and computed relative indices of inequality (RII). We observed large variations within Europe for educational differences in total cancer mortality among men and women. Three patterns were observed: Denmark, Norway and Sweden (significant RII around 1.3-1.4 among both men and women); France, Switzerland, Belgium and Finland (significant RII around 1.7-1.8 among men and around 1.2 among women); Spanish populations, Slovenia and Turin (significant RII from 1.29 to 1.88 among men; no differences among women except in the Basque region, where RII is significantly lower than 1). Lung, upper aerodigestive tract and breast cancers explained most of the variations between gender and populations in the magnitude of inequalities in total cancer mortality. Given time trends in cancer mortality, the gap in the magnitude of socioeconomic inequalities in cancer mortality between gender and between European populations will probably decrease in the future.

[Changing social disparities and mortality in France (1968-1996): cause of death analysis by educational level]. / Evolution temporelle des inégalités sociales de mortalité en France entre 1968 et 1996. Etude en fonction du niveau d'études par cause de décès.

BACKGROUND: Little information is available on temporal trend in socioeconomic inequalities in cause of death mortality in France. The aim of this paper was to study educational differences in mortality in France by cause of death and their temporal trend. METHODS: We used a representative sample of 1% of the French population and compared four periods (1968-1974, 1975-1981, 1982-1988, 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. Education was measured at the beginning of each period, and educational disparities in mortality were studied among men and women aged 30-64 at the beginning of each period. Analyses were conducted for all deaths and for the following causes of death: all cancers, lung cancer (among men), upper aerodigestive tract cancers (among men), breast cancer (among women), colorectal cancer, other cancers, cardiovascular diseases, ischaemic heart diseases, cerebrovascular diseases, other cardiovascular diseases, external causes, other causes of death. Socioeconomic inequalities were quantified with relative risks and relative indices of inequality. The relative indices of inequality measures socioeconomic inequalities across the population and can be interpreted as the ratio of mortality rates of those with the lowest to those with the highest socioeconomic status. RESULTS: Analyses showed an increase in educational differences in all cause mortality among men (the relative indices of inequality increased from 1.96 to 2.77 from the first to the last period) and among women (the relative indices of inequality increased from 1.87 to 2.53). Socioeconomic inequalities increased for all cause of death studied among women, and for cancer and cardiovascular diseases among men. The contribution of cancer mortality to difference in overall mortality between the lowest and the highest levels of education increased strongly over the whole study period, especially among women. CONCLUSION: This study shows that large socioeconomic inequalities in mortality are observed in France, and that they increase over time among men and women.

Social inequalities in breast cancer mortality among French women: disappearing educational disparities from 1968 to 1996.

We investigated the time trends in social inequalities in breast cancer mortality with an analysis by age at death and birth cohort using a representative 1% sample of the French population and four subcohorts (1968-1974, 1975-1981, 1982-1988 and 1990-1996). Causes of death were obtained by direct linkage with the French national death registry. Education was measured at the beginning of each period, and educational disparities in breast cancer mortality were studied among women aged 35-74 at the beginning of each period. In the 1970s, higher breast cancer mortality was found among higher educated women. This positive association progressively weakened and no association remained in the 1990s although it disappeared earlier among younger women. In an analysis by birth cohort, the same pattern was found among women born before 1925, whereas no association between education and mortality was observed among women born after 1925. Educational disparities in breast cancer mortality are currently changing and the previously observed positive gradient has disappeared. An important question is whether these relations are indirect, and due to changes in the prevalence of risk factors associated with education, but which we could not study.

Smoking, alcohol drinking and cancer risk for various sites of the larynx and hypopharynx. A case-control study in France.

The aim of this work was to study the effects of alcohol and tobacco consumption on laryngeal and hypopharyngeal cancer and to compare these across subsites (glottis, supraglottis, epilarynx, hypopharynx). Data from a hospital-based case-control study including 504 male cases (105 glottic cancers, 80 supraglottic cancers, 97 epilaryngeal cancers and 201 hypopharyngeal cancers) and 242 male controls with non-respiratory cancers were used for this analysis. Information about sociodemographic characteristics, detailed alcohol and tobacco consumption was collected through face-to-face interviews. Statistical analysis used logistic regression, and subsites were compared with polytomous logistic regressions. The risk of laryngeal and hypopharyngeal cancer increased with tobacco (duration and amount) and alcohol consumption; the effect of both agents was multiplicative. From the lowest to the highest consumption level, odds ratios ranged from 1.4 to 5.9 among regular drinkers and from 3 to 44 among current smokers. Risks among ex-smokers were approximately one-third of those for current smokers. Slightly elevated odds ratios were associated with consumption of black tobacco (OR=1.2) and hand-rolled cigarettes (OR=1.2). The risk of cancer was not clearly associated with the type of alcoholic beverage. Subsites did not differ significantly according to tobacco smoking, but differed according to alcohol consumption, with a significantly higher increased risk for hypopharyngeal than for glottic and supraglottic cancers.

Occupational exposures and lung cancer in New Caledonia.

AIMS: To study the associations between occupational exposures and the risk of lung cancer in New Caledonia. METHODS: All cases diagnosed between January 1993 and December 1995 (228 lung cancers) and 305 population controls were included. Detailed information on lifetime job history, smoking, and other potential risk factors was collected by interview. Occupational exposures were assessed from the questionnaires by an industrial hygienist, without knowledge of case-control status. RESULTS: No significant association was found with exposures related to nickel mining and refining, the main industrial activity in the territory. Among men, an excess risk of lung cancer was found for bus and truck drivers. Increased risks were also observed in men with the highest level of cumulative exposure to cleaning products and inorganic fertilisers. Exposure to field dust was associated with lung cancer risk in both sexes, and risk increased with cumulative exposure level. In some areas tremolite asbestos derived from local outcroppings was used as a whitewash. The association between exposure to field dust and lung cancer was limited to men and women exposed to this whitewash-that is, living in areas where the soil may contain tremolite. CONCLUSION: This study shows several associations between occupational exposures and lung cancer. The findings suggest that exposure to tremolite fibres from cultivated fields may increase the risk of lung cancer in New Caledonia.