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PubMed2005

Excess cardiac mortality on Monday: the importance of gender, age and hospitalisation.

BACKGROUND: Available evidence suggests a peak in the incidence of cardiovascular events on Mondays compared to other days of the week. The underlying mechanism may be summarised as naturally occurring rhythmic fluctuations in human physiology, and socially determined rhythms in human behaviour. Change in these rhythms may lead to attenuation of the peak on Mondays. OBJECTIVE: To quantify the excess risk associated with the Monday peak in cardiovascular mortality and to explore the role of age, gender and hospitalisation. METHODS: Details on time and cause of all deaths which occurred in the city of Rotterdam between November 21, 1988 and November 21, 1990 were obtained by sending a questionnaire to the physician who signed the death certificate. We studied the weekly distribution of 1828 confirmed cases of sudden cardiac death, for the group as a whole and in subgroups according to gender, age (< 65 years/65 years) and hospitalisation. RESULTS: The odds ratio (OR) of sudden cardiac death on Monday compared to other days of the week was 1.20 (95% CI: 1.06-1.36). The excess mortality due to the Monday peak amounted to 4.9 per 1000 deaths. The Monday peak was more pronounced in non-hospitalised (OR: 1.25; 95% CI: 1.08-1.44) than in hospitalised patients (OR: 1.06; 95% CI: 0.83-1.37), in men (OR: 1.25; 95% CI: 1.06-1.48) than in women (OR: 1.14; 95% CI: 0.95-1.36), and in those younger than 65 (OR: 1.29; 95% CI: 0.95-1.74) compared to those aged 65 years or over (OR: 1.18; 95% CI: 1.03-1.35). Yet, the confidence limits overlap. CONCLUSION: The incidence of sudden cardiac death is markedly increased on Monday, more pronounced in non-hospitalised patients. Our results may point to the relevance of naturally occurring rhythmic fluctuations in human physiology, and socially determined rhythms in human behaviour as underlying mechanism.

Adult↗
PubMedDate not supplied

Excess infant mortality in an American Indian population, 1940 to 1990.

OBJECTIVE: --To describe the infant mortality experience of an American Indian community and to demonstrate the utility of examining community-level mortality data. DESIGN: --Descriptive, population-based historical review of infant death certificates. SETTING: --The Warm Springs Indian Reservation, Oregon. PATIENTS OR OTHER PARTICIPANTS: --Infant tribal members of the Confederated Tribes of Warm Springs, 1940 to 1990. INTERVENTIONS: --None. MAIN OUTCOME MEASURES: --Categorization of causes of infant deaths and calculations of mortality rates. RESULTS: --The infant mortality rate, while lower in each decade since the 1940s, was still 2.6 times the national (all races) rate in the 1980s. Neonatal deaths did not account for many of the excess deaths. The postneonatal mortality rate has consistently been much greater than the national rate and was five times greater in the 1980s. Almost all of the excess infant mortality since 1980 has been due to the sudden infant death syndrome. CONCLUSIONS: --While there has been a dramatic decrease in infant mortality for this American Indian population, it remains higher than the national rate. Examining the causes of infant death has enabled this population to develop focused strategies to reduce infant mortality.

Cause of Death↗
PubMed2005

Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'.

OBJECTIVES: To determine the degree to which changing patterns of deprivation in Scotland and the rest of Great Britain between 1981 and 2001 explain Scotland's higher mortality rates over that period. DESIGN: Cross-sectional analyses using population and mortality data from around the 1981, 1991 and 2001 censuses. SETTING: Great Britain (GB). PARTICIPANTS: Populations of Great Britain enumerated in the 1981, 1991 and 2001 censuses. MAIN OUTCOME MEASURES: Carstairs deprivation scores derived for wards (England and Wales) and postcode sectors (Scotland). Mortality rates adjusted for age, sex and deprivation decile. RESULTS: Between 1981 and 2001 Scotland became less deprived relative to the rest of Great Britain. Age and sex standardized all-cause mortality rates decreased by approximately 25% across Great Britain, including Scotland but mortality rates were on average 12% higher in Scotland in 1981 rising to 15% higher in 2001. While over 60% of the excess mortality in 1981 could be explained by differences in deprivation profile, less than half the excess could be explained in 1991 and 2001. After adjusting for age, sex and deprivation, excess mortality in Scotland rose from 4.7% (95% CI: 3.9% to 5.4%) in 1981 to 7.9% (95% CI: 7.2% to 8.7%) in 1991 and 8.2% (95% CI: 7.4% to 9.0%) in 2001. All deprivation deciles showed excess indicating that populations in Scotland living in areas of comparable deprivation to populations in the rest of Great Britain always had higher mortality rates. By 2001 the largest excesses were found in the most deprived areas in Scotland with a 17% higher mortality rate in the most deprived decile compared to similarly deprived areas in England and Wales. Excess mortality in Scotland has increased most among males aged <65 years. CONCLUSIONS: Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.

Adolescent↗
PubMed2000

Long-term survival of prostate cancer in southeastern Netherlands.

With the increase in detection at an early stage, only a few and conflicting results have been reported on the long-term outcome for prostate cancer beyond 10 years. The vast majority of prostate cancer patients diagnosed between 1955 and 1984 in southeastern Netherlands, with a population of almost one million inhabitants, did not receive any curative treatment. We calculated the prognosis for 10-year survivors of prostate cancer diagnosed in the era preceding prostate-specific antigen (PSA) testing to determine how long these patients exhibited excess mortality. All patients under age 70 diagnosed with prostate cancer and registered in the population-based Eindhoven Cancer Registry between 1955 and 1984 were included in the study. Relative survival was calculated for those who survived for at least 10 years (n = 174). Initially, these patients still exhibited an almost 25% excess mortality risk, but this decreased with time and no excess mortality was found after 15 years.

Adult↗
PubMed1993

Does low cholesterol cause death?

Data linking low cholesterol with excess mortality have been gathered from both observational and clinical trials. The data are probably unrelated, as the levels of total cholesterol associated with excess mortality in observational studies are well below 160 mg/dl (4.1 mmol/l), whereas the levels achieved in clinical trials average around 230 mg/dl (5.9 mmol/l). Likely explanations of the association are that low cholesterol is a consequence of disease or is a confounder associated with other variables. The authors assess the relevance of the data to public health policy and medical practice. They conclude that evidence suggesting low cholesterol is a cause of excess mortality currently lacks breadth and rigor, and find no basis for changing cholesterol-management guidelines.

Cholesterol↗
PubMed1997

Alcohol abuse and mortality: a 40-year prospective study of Norwegian conscripts.

The availability of a 40-yr prospective study of more than 40,000 Norwegian men born in 1932-33 constituted the point of departure for assessing excess mortality in alcohol abusers as well as proportions of premature deaths in men attributable to alcohol abuse. The conscripts were medically examined at the military screening, alcohol abuse was categorized for those registered as admitted to alcohol treatment units over a 35-yr period from 1951 to 1987, and these data were further linked to the national death register in 1991. A total of 4468 men died before the age of 60 (10.8% of the sample). Alcohol abusers were found to have an overall excess mortality of 3.3, increasing with age. The cumulative risk of death before the age of 60 yr was estimated to 0.405 for the alcohol abusers, and at least 6.7% of all deaths before the age of 60 could be attributed to alcohol abuse. Presence of chronic diseases at conscription did not confound the estimates of excess mortality in alcohol abusers, neither was any significant interaction between chronic diseases at conscription and later alcohol abuse found with respect to mortality. The most prevalent causes of death in the total sample were, in descending order, cardiovascular diseases, malignant tumors, and accidents. The relative risks for alcohol abusers of death from accidents,cardiovascular diseases, and malignant tumors were estimated as 3.2, 2.5, and 1.8, respectively.

Adolescent↗
PubMed1987

Mortality after bereavement: a prospective study of 95,647 widowed persons.

The mortality of 95,647 persons, widowed during 1972-76 and identified by linking the Finnish Population Register and cause-of-death files, was followed up to the end of 1976. A total of 7,635 deaths during 225,251 person-years of experience were observed. Cause-specific standardized mortality ratios by time after bereavement were computed. The highest relative mortality risk was found immediately after bereavement. For all natural causes, mortality during the first week was over two-fold compared to expected rates. The relative risk was larger for ischemic heart disease (RR = 2.3 for men, and RR = 3.5 for women), an effect found in all age groups. Among men under age 65, excess mortality from IHD was also observed during later years of widowhood. For violent causes, exclusive of accidents simultaneously affecting both spouses, mortality was over two-fold during the first month. Mortality from suicides was greater than expected during the first years of widowhood. While the greatest excess mortality after bereavement seems to be due principally to the acute effects of becoming widowed, there also seems to be some excess mortality in younger persons widowed for a longer time.

Age Factors↗
PubMed1993

Cryptosporidiosis in infancy and childhood mortality in Guinea Bissau, west Africa.

OBJECTIVE: To investigate the epidemiology of and mortality from cryptosporidiosis in young children in Guinea Bissau, West Africa. DESIGN: Three year community study of an open cohort followed up weekly. SETTING: 301 randomly selected houses in a semi-urban area in the capital, Bissau. SUBJECTS: 1315 children aged less than 4 years. MAIN OUTCOME MEASURES: Cryptosporidium infection detected by examination of stools during episode of diarrhoea and death of a child. RESULTS: Cryptosporidium spp were found in 239 (7.4%) out of 3215 episodes of diarrhoea. The parasite was most common in younger children (median age 12 months) and at the beginning of the rainy seasons. The prevalence of cryptosporidiosis was 15% (77/513) in cases of persistent diarrhoea compared with 6.1% (148/2428) in diarrhoea lasting less than two weeks (p < 0.0001). Cryptosporidiosis was associated with excess mortality in children who had the infection in infancy, and this excess mortality persisted into the second year of life (relative mortality 2.9 (95% confidence interval 1.7 to 4.9)). The excess mortality could not be explained by malnutrition, or by socioeconomic factors, hygienic conditions, or breast feeding. CONCLUSIONS: Cryptosporidiosis is an important cause of death in otherwise healthy children in developing countries.

Child, Preschool↗
PubMed1989

Postoperative radiotherapy and late mortality: evidence from the Cancer Research Campaign trial for early breast cancer.

OBJECTIVE: To identify any excess mortality caused by adjuvant radiotherapy for early breast cancer. DESIGN: Prospective randomised clinical trial. Two thousand subjects needed for study to have a 90% chance of detecting a difference in survival rate of 7% with 95% significance. Patients were followed up until June 1988, giving follow up of 158-216 months. SETTING: A multicentre trial mainly drawing patients from centres in the United Kingdom. PATIENTS: 2800 Women presenting with clinical stage I or II carcinoma of the breast from June 1970 to April 1975. INTERVENTIONS: One group of women (n = 1376) had simple mastectomy followed by immediate postoperative radiotherapy (1320 to 1510 rets). The remaining women (n = 1424) had simple mastectomy with subsequent careful observation of the axilla, radiotherapy being delayed until there was obvious progression or recurrence of disease locally. END POINT: Increased mortality in patients treated with radiotherapy from causes other than breast cancer. MEASUREMENTS AND MAIN RESULTS: Survival was measured from time of first treatment to death or last follow up. Deaths from any cause and from specified causes were counted as events. Comparison over the whole follow up showed a slight excess mortality in the group treated with radiotherapy (relative risk 1.04; 95% confidence interval 0.94 to 1.15). The relative risk of death from breast cancer was 0.97 (0.87 to 1.08) but that of death from other causes was 1.37 (1.09 to 1.72), the increase mainly being in women who had had tumours of the left breast (1.61 (1.17 to 2.24)) and had been treated with orthovoltage (1.85 (1.27 to 2.71)). Analysis of causes of death after five years showed a relative risk of 2.11 (1.25 to 3.59) for new malignancies and of 1.65 (1.05 to 2.58) for cardiac disease, the increase in cardiac mortality being most pronounced in patients who had had tumours of the left breast and whose treatment had included orthovoltage radiation (relative risk 2.67 (1.28 to 5.55)). CONCLUSIONS: Adjuvant radiotherapy after simple mastectomy for early breast cancer produces a small excess late mortality from other cancers and cardiac disease. The risk has to be balanced against the higher risk of local recurrence when immediate postoperative radiotherapy is not given. The balance has to be assessed for each patient, and for many patients radiotherapy will still be desirable in the initial treatment of their early breast cancer.

Breast Neoplasms↗
PubMed1995

[Long-term prognosis of pulmonary sarcoidosis. 1. Prognostic value of lung function and symptoms].

A follow-up of 254 patients with intrathoracic sarcoidosis has been carried out after a median of 27 years from diagnosis. All patients could be traced. No excess mortality was found (80 deaths observed versus 66 expected). The causes of death were related to sarcoidosis in 41%. X-ray stage was related to survival with a significant excess mortality for stage 3. Early clearing of X-ray changes gave a favourable vital prognosis. Survival was related to lung function, especially forced expiratory volume in 1 second (FEV1) and total lung capacity (TLC). All deaths from sarcoidosis were seen among patients with respiratory symptoms at presentation. For sarcoidosis & sarcoidosis-related deaths (N = 33), presence of one or more of the respiratory symptoms increased the risk significantly. For overall mortality respiratory symptoms were also significant predictors; this was the case even after adjusting for age, sex, x-ray stage and lung function (FEV1 & TLC) at presentation. In conclusion, no excess mortality was observed after a median of 27 years follow-up. Lung function, respiratory symptoms and to some extent X-ray stage at time of diagnosis influenced long-term mortality in patients with intrathoracic sarcoidosis.

Adult↗
PubMed2003

Excess winter mortality in Europe: a cross country analysis identifying key risk factors.

OBJECTIVE: Much debate remains regarding why certain countries experience dramatically higher winter mortality. Potential causative factors other than cold exposure have rarely been analysed. Comparatively less research exists on excess winter deaths in southern Europe. Multiple time series data on a variety of risk factors are analysed against seasonal-mortality patterns in 14 European countries to identify key relations Subjects and setting: Excess winter deaths (all causes), 1988-97, EU-14. DESIGN: Coefficients of seasonal variation in mortality are calculated for EU-14 using monthly mortality data. Comparable, longitudinal datasets on risk factors pertaining to climate, macroeconomy, health care, lifestyle, socioeconomics, and housing were also obtained. Poisson regression identifies seasonality relations over time. RESULTS: Portugal suffers from the highest rates of excess winter mortality (28%, CI=25% to 31%) followed jointly by Spain (21%, CI=19% to 23%), and Ireland (21%, CI=18% to 24%). Cross country variations in mean winter environmental temperature (regression coefficient (beta)=0.27), mean winter relative humidity (beta=0.54), parity adjusted per capita national income (beta=1.08), per capita health expenditure (beta=-1.19), rates of income poverty (beta=-0.47), inequality (beta=0.97), deprivation (beta=0.11), and fuel poverty (beta=0.44), and several indicators of residential thermal standards are found to be significantly related to variations in relative excess winter mortality at the 5% level. The strong, positive relation with environmental temperature and strong negative relation with thermal efficiency indicate that housing standards in southern and western Europe play strong parts in such seasonality. CONCLUSIONS: High seasonal mortality in southern and western Europe could be reduced through improved protection from the cold indoors, increased public spending on health care, and improved socioeconomic circumstances resulting in more equitable income distribution.

Climate↗
PubMed1992

Mortality differentials between three populations--residents of Scandinavia, Scandinavian immigrants to Canada and Canadian-born residents of Canada, 1979-1985.

The study compares the mortality of Canadian residents born in Canada and Scandinavia (Finland, Sweden, Norway, Denmark) to the mortality of the four Scandinavian countries. The study focuses on the mortality experience of anyone who was 35-74 years old during the period 1979-85. Swedish and Norwegian populations both in Scandinavia as well as immigrants to Canada had relatively low mortality from all causes of death. On the other hand, populations in Finland and Denmark had comparatively higher mortality from certain causes of death. Finnish excess mortality from cardiovascular diseases and from external causes of death was present in Finnish living in Scandinavia as well as in Finnish immigrants to Canada. This contrasted with the excess mortality from non-cardiovascular disease in the population of Denmark which was not reflected in the mortality of Danish immigrants to Canada. Finally, the cardiovascular mortality of all Scandinavian-born immigrants to Canada was found to be lower than in their respective countries of origin. The article includes a discussion of possible explanations for these results.

Adult↗
PubMed1989

Changes in seasonal mortalities with improvement in home heating in England and Wales from 1964 to 1984.

Changes in summer (July-September) and winter (January-March) mortalities of people aged 70-74 in England and Wales from 1964 to 1984 were compared with possible causal factors. Summer mortalities were little affected by annual temperature or influenza epidemics and fell from 1972-1975 for all causes, coronary and respiratory causes, while cerebrovascular mortality fell more rapidly from that time. Cigarette consumption also fell from 1972-1975; falling consumptions of total fat from 1970 and saturated fat from 1972-1975 probably also contributed to the fall in arterial deaths, and likewise falls in prescription rates for tranquillisers and sedatives from 1976-1978 to the fall in respiratory deaths. From 1964 to 1984 use of central heating increased from 13% to 69% of households, domestic fuel consumption increased, and excess mortality in winter from respiratory disease declined by 69%, even relative to summer mortality and when adjusted for varying coldness of winters. The improvement was partly explained by a decline in influenza epidemics. By contrast, excess mortalities in winter from coronary and cerebrovascular disease, although rising in some early influenza epidemics, did not fall significantly as home heating improved. These thrombotic deaths together accounted for 56% of the total excess winter mortality by 1984. The findings support other indications that most of the excess mortality from arterial thrombosis in winter in England and Wales is due to brief excursions outdoors rather than to low indoor temperatures.

Aged↗
PubMed1998

Mortality and causes of death of 344 Danish patients with systemic sclerosis (scleroderma)

OBJECTIVE: To determine survival, mortality and causes of death in Danish patients with systemic sclerosis (scleroderma), and to analyse how these parameters are influenced by demographic variables and the extent of skin involvement. METHODS: A cohort of 344 patients with incident systemic sclerosis (SSc) after 1 January 1960 was retrospectively identified, representing 3716 patient-years of follow-up. The vital status at the end of the study ultimo 1996 was established by reviewing the clinical charts and by contacting the Danish Central Person Register. The causes of death were based on information obtained from the hospital charts and the autopsy reports (80%) and death certificates (20%). The extent of skin sclerosis was described by means of a two-subset model (limited and diffuse involvement) and a three-subset model (digital, extremity and truncal involvement) in all patients. Expected numbers of deaths were calculated by means of age- and sex-specific mortality rates of the general Danish population. RESULTS: Crude mortality rates were 6.5 and 3.9%/yr, respectively, in men and women. The standardized mortality ratio (SMR) was 2.9 (95% CI 2.5-3.4) and was not significantly influenced by sex or age at disease onset. Mortality rates were significantly increased in patients with diffuse skin sclerosis (SMR 4.5, 95% CI 3.5-5.7) and patients under the age of 35 yr (SMR 13, 95% CI 2.7-37). Of the 160 patients who died during the study, 41 deaths (26%) were SSc related, accounting for one-third of the excess mortality. CONCLUSION: We found a significantly increased mortality in patients with SSc, particularly in the subset of patients with diffuse skin sclerosis and in young patients. The excess mortality was due to an increase in both the SSc-related mortality and the unrelated mortality. However, all other subsets also had a significantly increased risk of death, mainly due to an increased risk of death due to causes unrelated to SSc, cancer among others. The fact that the unrelated mortality in SSc was found to be 2-fold increased suggests that the excess mortality that was classified as unrelated should more appropriately be termed indirectly SSc related.

Adolescent↗
PubMed1988

A cohort mortality study of employees exposed to chlorinated chemicals.

The cohort of this historical prospective mortality study consisted of 697 male employees at a chlorination plant. A majority of the cohort was potentially exposed to benzotrichloride, benzyl chloride, benzoyl chloride, and other related chemicals. The mortality experience of the cohort was observed from 1943 through 1982. For the cohort as a whole, no statistically significant mortality excess was detected. The overall Standardized Mortality Ratio (SMR) was 100, and the SMR for all cancers combined was 122 (not significant). The respiratory cancer SMR for the cohort as a whole was 246 (7 observed vs. 2.8 expected). The excess was of borderline statistical significance, the lower 95% confidence limit being 99. Analysis by race showed that all 7 respiratory cancer deaths came from the white male employees, with an SMR of 265 (p less than 0.05). The respiratory cancer mortality excess was higher among employees in maintenance (SMR = 229) than among those in operations or production (SMR = 178). The lung cancer mortality excess among the laboratory employees was statistically significant (SMR = 1292). However, this observation should be viewed with caution, since it was based on only 2 deaths. Further analysis indicated that the respiratory cancer mortality excess was limited to the male employees with 15 or more years of employment (SMR = 379, p less than 0.05). Based on animal data as well as other epidemiologic studies, together with the internal consistency of analysis by length of employment, the data suggest an association between the chlorination process of toluene at the plant and an increased risk of respiratory cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Mortality among psychiatric patients--the groups at risk.

This study examined standardized mortality ratios (SMR) among the patients who had undergone psychiatric hospitalization in Israel in 1978. The size of the sample (83,175 person-years) allowed us to calculate simultaneously SMR by age, sex, diagnosis and cause of death. The global SMR was 2.3 and decreased with age. Excess mortality was found in patients from all diagnostic groups for death from both natural and unnatural causes. Excess mortality from cancer was found only among patients aged under 40. The SMR for death by suicide was lower than that reported in the literature. The highest excess mortality was due to respiratory and infectious diseases in all groups and especially among young alcoholics and drug addicts (SMR = 273). This points to the importance of an ongoing follow-up of the physical health of psychiatric patients.

Adolescent↗
PubMed2005

Mortality in individuals with severe deficiency of alpha1-antitrypsin: findings from the National Heart, Lung, and Blood Institute Registry.

STUDY OBJECTIVE: To clarify the mortality rate and causes of death of individuals with alpha(1)-antitrypsin (AAT) deficiency, the Death Review Committee (DRC) of the National Heart, Lung, and Blood Institute Registry of Individuals with Severe AAT Deficiency reviewed all available medical records regarding the deaths of study subjects during Registry follow-up (up to 7.2 years). METHODS: Individual determinations by each member of the three-person DRC led to consensus judgments regarding the underlying cause and the immediate and contributing causes of death. RESULTS: Of the 1,129 Registry subjects, 204 died (18.1%) [approximately 3%/yr]. Record availability permitted detailed review in 120 decedents, and death certificates were available in 56 of the remaining 84 subjects (67%). Emphysema and cirrhosis were the most common underlying causes of death (72% and 10%, respectively), with malignancy and diverticulitis accounting for 3% of deaths each. To assess attributable mortality, standardized mortality ratio analysis was performed and indicated that excess mortality was ascribable entirely to lung and liver disease. CONCLUSIONS: We conclude that severe AAT deficiency poses a significant threat to health, that severe airflow obstruction is a major determinant of mortality, and that liver and lung disease account for the excess mortality in affected individuals. These findings support current efforts to enhance diagnostic recognition and treatment of AAT-deficient individuals.

Adult↗
PubMed1998

Why is mortality higher in poorer areas and in more northern areas of England and Wales?

STUDY OBJECTIVE: To identify and quantify the factors responsible for the differences in mortality between affluent and deprived areas, the north and the south, and urban and rural areas in England and Wales. DESIGN: A multiple Poisson regression analysis of cause specific mortality in the 403 local authority districts, each classified by deprivation (using the Jarman Index), latitude (from 50 degrees to 55 degrees north) and urbanisation, adjusting for age, sex, and proportion of ethnic minorities. SETTING: England and Wales 1992. MAIN RESULTS: All cause mortality was 15% higher in the districts comprising the most compared with the least deprived tenth of the population, 23% higher in the most northern (55 degrees) than in the most southern (50 degrees) districts, and 4% higher in metropolitan (within large cities) than rural districts. Nationally these differences were associated with 40,000, 65,000, and 15,000 excess deaths respectively. More than two thirds of the overall excess mortality with deprivation, latitude, and urbanisation was from three diseases--ischaemic heart disease, lung cancer, and chronic bronchitis and emphysema. The excess mortality from these and other diseases closely matched that predicted from differences according to deprivation and latitude in smoking, heavy alcohol consumption, Helicobacter pylori infection, and temperature, and thus could be attributed to these causes. About 85% of the overall excess mortality with deprivation was attributable to heavier smoking and 6% to heavier alcohol consumption, but diet varied little. Deaths more directly related to deprivation (such as those caused by H pylori infection, drug misuse, psychoses) accounted for an estimated 12% of the excess deaths, but variation in provision and uptake of healthcare services only 1%. The direct effects of deprivation are more strongly related to morbidity than mortality. Of the difference in mortality with latitude, about 45% was attributable to differences in smoking, and 25% to climate (mainly the association of cardiovascular and respiratory disease with cold). The differences with urbanisation were mainly because of smoking. CONCLUSIONS: Differences in the prevalence of smoking account for much of the variation in mortality between areas. Alcohol accounts for some, diet little. The more direct material effect of deprivation contributes to the variation in mortality but is particularly important with respect to differences in morbidity.

Age Factors↗