Lifetime socioeconomic position and mortality: prospective observational studyBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7080.547 (Published 22 February 1997) Cite this as: BMJ 1997;314:547
- George Davey Smith, professor of clinical epidemiologya,
- Carole Hart, statisticianb,
- David Blane, senior lecturer in medical sociologyc,
- Charles Gillis, directord,
- Victor Hawthorne, professor of epidemiologye
- a Department of Social Medicine, University of Bristol, Bristol BS8 2PR
- b Department of Public Health, University of Glasgow, Glasgow G12 8RZ
- c Academic Department of Psychiatry, Charing Cross and Westminster Medical School, London W6 8RP
- d West of Scotland Cancer Surveillance Unit, Ruchill Hospital, Glasgow G20 9NB
- e University of Michigan, School of Public Health, Department of Epidemiology, 109 Observatory Road, Ann Arbor, MI 48109, USA
- Correspondence to: Professor Davey Smith
- Accepted 18 December 1996
Objectives: To assess the influence of socioeconomic position over a lifetime on risk factors for cardiovascular disease, on morbidity, and on mortality from various causes.
Design: Prospective observational study with 21 years of follow up. Social class was determined as manual or non-manual at three stages of participants' lives: from the social class of their father's job, the social class of their first job, and the social class of their job at the time of screening. A cumulative social class indicator was constructed, ranging from non-manual social class at all three stages of life to manual social class at all three stages.
Setting: 27 workplaces in the west of Scotland.
Participants: 5766 men aged 35-64 at the time of examination.
Main outcome measures: Prevalence and level of risk factors for cardiovascular disease; morbidity; and mortality from broad causes of death.
Results: From non-manual social class locations at all three life stages to manual at all stages there were strong positive trends for blood pressure, body mass index, current cigarette smoking, angina, and bronchitis. Inverse trends were seen for height, cholesterol concentration, lung function, and being an ex-smoker. 1580 men died during follow up. Age adjusted relative death rates in comparison with the men of non-manual social class locations at all three stages of life were 1.29 (95% confidence interval 1.08 to 1.56) in men of two non-manual and one manual social class; 1.45 (1.21 to 1.73) in men of two manual and one non-manual social class; and 1.71 (1.46 to 2.01) in men of manual social class at all three stages. Mortality from cardiovascular disease showed a similar graded association with cumulative social class. Mortality from cancer was mainly raised among men of manual social class at all three stages. Adjustment for a wide range of risk factors caused little attenuation in the association of cumulative social class with mortality from all causes and from cardiovascular disease; greater attenuation was seen in the association with mortality from non-cardiovascular, non-cancer disease. Fathers having a non-manual occupation was strongly associated with mortality from cardiovascular disease: relative rate 1.41 (1.15 to 1.72). Participants' social class at the time of screening was more strongly associated than the other social class indicators with mortality from cancer and from non-cardiovascular, non-cancer causes.
Conclusions: Socioeconomic factors acting over the lifetime affect health and risk of premature death. The relative importance of influences at different stages varies for the cause of death. Studies with data on socioeconomic circumstances at only one stage of life are inadequate for fully elucidating the contribution of socioeconomic factors to health and mortality risk.
Health and risk of premature death are determined by socioeconomic factors acting throughout life
Socioeconomic influences on particular causes of death may have different critical times
The risk of premature death from cardiovascular disease is particularly sensitive to socioeconomic influences acting in early life
Studies with data on socioeconomic circumstances at only one stage of life are inadequate for fully elucidating the contribution of socioeconomic factors to health
- Accepted 18 December 1996