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Magnitude and Causes Whitehall Study Journal of Epidemiology and Community Health 1990; 44: 265-270 Magnitude and causes of socioeconomic J Epidemiol Community Health: first published as 10.1136/jech.44.4.265 on 1 December 1990. Downloaded from differentials in mortality: further evidence from the Whitehall Study George Davey Smith, Martin J Shipley, Geoffrey Rose Abstract shown to account for the differentials in Study objective-The aim was to explore mortality, although the degree to which this the magnitude and causes of the differences can be explored with single measurements in mortality rates according to socio- is limited. economic position in a cohort of civil servants. Design-This was a prospective Since the 1911 census the classification of observational study of civil servants occupations into the Registrar General's social followed up for 10 years after baseline data classes (RGSC) has been the basis for the coliection. examination of socioeconomic differentials in Setting-Civil service offices in London. mortality rates.' As the inventor of this system Participants-11 678 male civil servants made clear, it was intended to categorise people were studied, aged 40-64 at baseline according to their degree of material well being screening between 1967 and 1969. Two among other factors.2 ' Since then information indices of socioeconomic position were generated from the analysis ofmortality according available on these participants-employ- to RGSC has been used to support the notion that ment grade (categorised into four levels), lower living standards are associated with higher and ownership of a car. death rates.>5 Measurements and main results-Main The appropriateness of the RGSC for outcome measures were all cause and cause examining socioeconomic differences in mortality specific mortality, with cause ofdeath taken has been questioned and defended from several from death certificates coded according to standpoints.'9 This categorisation is imprecise in the eighth revision of the ICD. Employ- regard to income-within class variation in ment grade and car ownership were income is greater than that between classes.'0 independently related to total mortality and Other factors within the social environment will to mortality from the major cause groups. also be distributed more unevenly than the Combining the indices further improved Registrar General's social class categorisation definition of mortality risk and the age would suggest. Thus estimates from social class adjusted relative rate between the highest analysis will attenuate the underlying associations grade car owners and the lowest grade non- between material and social well being and owners of4-3 is considerably larger than the mortality." The OPCS Longitudinal Study has social class differentials seen in the British explored this by combining other indicators of http://jech.bmj.com/ population. Factors potentially involved in socioeconomic position-housing tenure and the production of these mortality occupancy, possession of household amenities, differentials were examined. Smoking, car ownership, and level of education-with the plasma cholesterol concentration, blood Registrar General's social classes in the pressure, and glucose intolerance did not examination of mortality and cancer registration appear to account for them. The pattern of rates.12-4 In general, being an owner-occupier, differentials was the same in the group who possessing household amenities and a car, having on September 26, 2021 by guest. Protected copyright. reported no ill health at baseline as it was in had higher education and being in a higher social the whole sample, which suggests that class group were related to lower mortality and health selection associated with frank illness cancer registration rates. When these was not a major determinant. The classifications were combined, independent contribution of height, a marker for effects were seen. This suggests that the effects of environmental factors acting in early life, socioeconomic environment upon health are not was also investigated. Whereas adjustment adequately characterised by the use of social class Department of for employment grade and car ownership categories alone. Better discrimination is achieved Epidemiology and Population Sciences, attenuated the association between short by combining indicators of socioeconomic London School of stature and mortality, height differences position. Hygiene and Tropical within employment grade and car Complementary findings have come from Medicine, Keppel St., the London WC1E 7HT ownership groups explained little of the follow up of a cohort study of civil servants, G Davey Smith differential mortality. Whitehall Study, in which employment grade M J Shipley Conclusion-The use of social class as an has served as the marker of socioeconomic G Rose index of socioeconomic position leads to position. 1517 The differences in 10 year mortality Correspondence to: underestimation of the association between rates between grades were considerably greater Dr Davey Smith social factors and mortality, which may be than the Decennial Supplements suggested. 10 It is of interest to see if further refinement of Accepted for publication reflected in public health initiatives and May 1990 priorities. Known risk factors could not be categorisation in the Whitehall Study leads to 266 George Davey Smith, Martin J Shipley, Geoffrey Rose increases in differentials. The availability of data manual jobs). Smoking has been categorised J Epidemiol Community Health: first published as 10.1136/jech.44.4.265 on 1 December 1990. Downloaded from regarding car ownership allows this to be according to cigarette use as "current smoker", examined. Having access to a car was the strongest "ex-smoker" and "never smoker". The 409 men independent predictor of mortality among men who smoked pipes or cigars only have been who could be assigned to a social class in the excluded from the analyses that involve smoking Longitudinal Study."8 Thus the combination of status. employment grade and car ownership provides a Data were missing for car ownership (5), blood test of the hypothesis that more precise pressure (3), cholesterol (556), glucose tolerance classification of socioeconomic position increases (90), body mass index (2), and smoking status (3). the mortality differentials observed. Subjects were only excluded from the analyses for The present study examines the independent which their specific data were missing. and combined effects of employment grade and Records from over 99% of subjects were traced car ownership on mortality. The 10 year follow up and flagged at the National Health Service data are examined, as mortality over this period Central Registry. Death certificates coded corresponds best with the Decennial according to the eighth revision of the Supplements, which only cover men aged 64 years International Classification of Diseases (ICD) and under. Analyses are repeated after excluding have been obtained, and this almost complete men sick at the time of screening, to allow the mortality follow up provides the basis for this effects of selection to be explored. The degree to analysis. Mortality has been classified as being which differences in smoking, blood pressure, due to cardiovascular disease (CVD; ICD codes plasma cholesterol concentration, and glucose 390-458), neoplasms (ICD codes 140-239), or tolerance can explain mortality differentials is also other causes. For seven deaths the cause was examined. unknown. These have been included in all cause It has been postulated that factors acting during mortality, but have been excluded from analyses early life are related to the risk of cardiovascular of cause specific mortality. Mortality causes have disease in adulthood.'9 Height is influenced both also been classified according to whether smoking by genetic factors and by childhood environ- is considered to play a role in their aetiology.2"29 ment.20 21 Short stature is associated with higher The causes deemed to be smoking related, with mortality risk in the Whitehall study,'7 a finding their ICD codes, are: malignant neoplasms of the in line with other investigations which have lip (ICD 140), tongue (141), mouth and pharynx related markers ofearly environmental conditions (143-149), oesophagus (150), pancreas (157), to mortality.22 23 The possible role of conditions respiratory system (160-163), and urinary system in childhood, as indexed by height, in the (188-189); hypertensive disease (400-404); generation ofsocioeconomic position differentials ischaemic heart disease (410-414); pulmonary in mortality in adulthood is investigated in the heart disease (426); cerebrovascular disease (430- present cohort. 438); diseases of the arteries, arterioles and capillaries (440-448); pneumonia (480-486); bronchitis and emphysema (491-492); and peptic Methods ulcer (531-534). In the Whitehall study 18 403 men aged 40-64 Mortality rates have been calculated using were examined between 1967 and 1969.24 person years at risk. These rates and also all means Measurements included height, weight, blood and proportions have been standardised for age at pressure, a six lead electrocardiogram, plasma entry by the direct method, using the study cholesterol concentration, and a glucose tolerance population as the standard. Adjustment for other http://jech.bmj.com/ test. A questionnaire was completed regarding major risk factors and calculation of confidence age, civil service employment grade, smoking intervals for the relative risks was done using habits,
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