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The First Whitehall Study Mortality. a 25 Year Follow up of Civil Servants From Downloaded from jech.bmj.com on 4 December 2006 Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study Caroline T M van Rossum, Martin J Shipley, Hendrike van de Mheen, Diederick E Grobbee and Michael G Marmot J. Epidemiol. Community Health 2000;54;178-184 doi:10.1136/jech.54.3.178 Updated information and services can be found at: http://jech.bmj.com/cgi/content/full/54/3/178 These include: References This article cites 16 articles, 9 of which can be accessed free at: http://jech.bmj.com/cgi/content/full/54/3/178#BIBL 20 online articles that cite this article can be accessed at: http://jech.bmj.com/cgi/content/full/54/3/178#otherarticles Rapid responses You can respond to this article at: http://jech.bmj.com/cgi/eletter-submit/54/3/178 Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to Journal of Epidemiology and Community Health go to: http://www.bmjjournals.com/subscriptions/ Downloaded from jech.bmj.com on 4 December 2006 178 J Epidemiol Community Health 2000;54:178–184 Employment grade diVerences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study CarolineTMvanRossum, Martin J Shipley, Hendrike van de Mheen, Diederick E Grobbee, Michael G Marmot Abstract of these risk factors on these employment Study objective—To test the hypothesis grade diVerences in mortality rates were also that the association between socioeco- investigated. nomic status and mortality rates cuts In addition, we might expect the socioeco- across the major causes of death for mid- nomic diVerences in mortality to be less dle aged and elderly men. pronounced in old age, as the eventual Design—25 year follow up of mortality in probability of death for each person reaches relation to employment grade. 100%. However, social class diVerentials in Setting—The first Whitehall study. mortality are still found in these age groups.8–11 Participants—18 001 male civil servants A previous analysis of the 25 year follow up aged 40–69 years who attended the initial data from the first Whitehall study has shown screening between 1967 and 1970 and were that relative diVerences in mortality between followed up for at least 25 years. socioeconomic groups decrease but still persist Main outcome measure—Specific causes beyond retirement age and in absolute terms of death. even increase with old age.12 The question Results—After more than 25 years of arises whether this applies to diVerent causes of follow up of civil servants, aged 40–69 death to the same extent or whether there are years at entry to the study, employment some causes where the grade eVects disappear grade diVerences still exist in total mor- after retirement age. Therefore, we have exam- tality and for nearly all specific causes of ined whether the employment grade eVects death. Main risk factors (cholesterol, decreased with more years of follow up and smoking, systolic blood pressure, glucose whether these associations diVer between mid- intolerance and diabetes) could only ex- dle aged men and older retired men. plain one third of this gradient. Compar- ing the older retired group with the Methods A total of 19 019 civil servants aged 40–69 years Department of younger pre-retirement group, the diVer- Epidemiology and entials in mortality remained but were attended the initial screening of the Whitehall Biostatistics, Erasmus less pronounced. The largest decline was study between September 1967 and January University Rotterdam, seen for chronic bronchitis, gastro- 1970. In short, each participant filled in a stand- the Netherlands intestinal diseases and genitourinary dis- ard questionnaire that included age, self re- CTMvanRossum eases. ported smoking habit, civil servants’ employ- ment grade, and health status. Measurements at Department of Public Conclusions—DiVerentials in mortality Health, Erasmus persist at older ages for almost all causes the screening examination included blood pres- University Rotterdam of death. sure, plasma cholesterol concentration and a H van de Mheen (J Epidemiol Community Health 2000;54:178–184) glucose tolerance test. Subjects with a blood glucose, two hours after a post-fasting 50 g glu- International Centre cose load, above 11.1 mmol/l or with previously for Health and Society, An association between socioeconomic status diagnosed diabetes constituted the diabetic Department of and mortality has been shown in several studies group; non-diabetic subjects with glucose con- Epidemiology and 1–5 Public Health, and countries. Marmot et al suggested that centrations above the 95th centile point (5.4– University College there was a general susceptibility to specific 11.0 mmol/l) formed the group with impaired London Medical causes of death, as after a 10 year follow up of glucose tolerance, and other subjects were School, 1–19 British civil servants in the first Whitehall study designated as being normoglycaemic. Smoking Torrington Place, an inverse gradient by employment grade was has been categorised according to cigarette use London WC1E 6BT 6 M J Shipley seen for most causes of death. However, the as current smokers, ex-smoker and never M G Marmot number of events used in this analysis was rela- smoker. More details regarding design and tively small. After 25 years of follow up of this methods are described elsewhere.13 Employ- Julius Center for study population, it is possible to examine ment grade was categorised as administrative, Patient Oriented these associations again with many more professional and executive, clerical, and “other” Research, Utrecht events. Furthermore, it was possible to exam- grades (for example, messengers and other University, the Netherlands ine the diversity in the gradients by causes of unskilled manual workers). For 886 men from D E Grobbee death and to examine even more specific causes the Diplomatic Service and the British Council, of death. employment grade was not comparable with the Correspondence to: In previous analyses, employment grade dif- grades above and these men have been excluded Professor M G Marmot ferences have been partly explained by the bio- from the analyses. Accepted for publication logical and behavioural factors of smoking, Records from 99.3% of the remaining men 14 September 1999 blood pressure and cholesterol.257The impact were flagged at the National Health Service Downloaded from jech.bmj.com on 4 December 2006 Employment grade diVerences in cause specific mortality 179 Central Registry, which notified us of all deaths data from the relatively small groups of the up to the end of January 1995. Causes were “other” grade and administrative grade, are classified according to the International Classi- used. fication of Disease, eighth revision (ICD-8). A To examine the impact of risk factors on total of 18 001 men were followed up for at these employment grade diVerences, mortality least 25 years and contributed a total of rate ratios among subjects who are not 385 660 person years with 8053 deaths. For currently smoking and who have a low plasma another 21 subjects the cause of death was cholesterol level (below the median of 5.0 missing, these have been excluded from the mmol/l) and a low systolic blood pressure cause specific mortality analysis. (below 133 mm Hg) were estimated. In addition, the mortality rate ratios based on the DATA ANALYSIS whole population were adjusted for several risk Mortality rates have been calculated using per- factors: smoking, systolic blood pressure, son years at risk. These rates have been stand- ardised for age at entry by the direct method, glucose intolerance and diabetes, and choles- using five year age bands and with the total terol. population as the standard. The mortality gra- To compare the employment grade diVer- dients across the four employment grades are ences for three diVerent intervals of follow up close to linear. Therefore, to compare the (0–9, 10–19, 20+ years), we split our dataset trends across the employment grade levels into three parts and computed age adjusted between several causes of death we estimated rate ratios for the four employment grades tak- the rate ratio between the lowest and the high- ing the professional/executive as the reference est employment grade using Cox’s propor- group as the administrative grade had relatively tional hazards models in which employment small numbers. grade was added as a continuous variable For the analysis of the age specific mortality (values 1, 2, 3, and 4). We estimated the rate diVerentials we also created a new expanded ratio between the highest (that is, administra- dataset in which for each individual year of fol- tive) and the lowest employment grade (that is, low up a new record was created, consisting of “others”) by taking the exponent of three times each man’s current age at risk together with his the coeYcient for employment grade. This employment grade and length of follow up in method has the advantage of giving a more that year. Deaths were allocated to the stable estimate as all the data, rather just the appropriate current age category. This dataset Table 1 Age adjusted mortality rates per 1000 person years (number of deaths) by employment grade and mortality rate ratios for “other” grade versus administrative* Mortality rates (number of deaths) Mortality rate ratio (95% CI) “Other” Administrative Professional/ executive Clerical Other grade versus Causes of death (ICD-8) (n=962) (n=12 269) (n=2981) (n=1789) Administrative* All causes 16.76 (295) 20.74 (4733) 27.43 (1779) 30.91 (1246) 2.07 (1.90,2.25) Malignant neoplasm of lung (162.1) 0.76 (16) 1.53 (358) 2.80 (181) 3.28 (147) 4.08 (3.10,5.38) Other neoplasms (140-239 excl.
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