National and education-specific trends in life and health expectancies in Denmark 2004-2015.

BACKGROUND: Several studies have revealed widening of inequalities in life expectancy, but little is known about the recent changes in health expectancy nationally and between socioeconomic groups. This study examines dynamics of national and education-specific life expectancy and health expectancies at age 50 years in Denmark from 2004/2007 to 2015. METHODS: Nationwide register data on education and mortality were linked and combined with Danish health data from the Survey of Health, Ageing and Retirement in Europe and changes in life expectancy and three health expectancy indicators were estimated by Sullivan's method. RESULTS: From 2004 to 2015, national life expectancy at age 50 years increased by 2.4 years for men and 2.1 years for women. Simultaneously, after an initial rapid improvement from 2004 to 2007, the pace of progress in health expectancy decreased. From 2007 to 2015, the difference in life expectancy at age 50 years between men with long and short education increased from 4.3 to 5.0 years. For women, the corresponding increase in the life expectancy gap was less pronounced from 3.5 to 3.8 years. The educational gap in lifetime without long-term illness decreased from 4.6 years to 3.1 years for men and from 6.1 years to 4.6 years for women. On the contrary, the educational gap increased for lifetime without activity limitations and in self-rated good health. CONCLUSIONS: Previously observed improvements in health expectancy in Denmark slowed down despite continuing progress in life expectancy. This worrying change coincides with persistent educational inequalities in life expectancy and health expectancy and is a challenge to a sustainable social and health development in the future.

Impact of the association between education and obesity on diabetes-free life expectancy.

BACKGROUND: The purpose of the study was to quantify the association between body weight and health by estimating the expected lifetime with and without diabetes (diabetes-free life expectancy) at age 30 and 65. In addition, the diabetes-free life expectancy was stratified by educational level. METHODS: Life tables by sex, level of education and obese/not obese were constructed using nationwide register data and self-reported data on body weight and height and diabetes from the Danish National Health Survey in 2021. Diabetes-free life expectancies were estimated by Sullivan's method. RESULTS: The difference in life expectancy between not obese 30-year-old men with a long and a short education was 5.7 years. For not obese women, the difference was 4.1 years. For obese men and women, the difference in life expectancy at age 30 was 7.0 and 5.2 years. Women could expect more years without and fewer years with diabetes than men regardless of body weight and educational level. Diabetes-free life expectancy differed by 6.9 years between not obese 30-year-old men with a short and a long education and by 7.7 years for obese men with a short and a long education. For women, the differences were 5.9 and 6.6 years. CONCLUSION: The results demonstrate an association of obesity and educational level with life expectancy and diabetes-free life expectancy. There is a need for preventive efforts to reduce educational inequality in life expectancy and diabetes-free life expectancy. Structural intervention will particularly benefit overweight people with short education.

Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study.

AIMS/HYPOTHESIS: High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities. METHODS: Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40-59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension. RESULTS: Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity. CONCLUSIONS/INTERPRETATION: In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people.

Method for reconstructing mortality by educational groups.

BACKGROUND: The lack of classification by educational attainment in death and population exposure data at older ages is an important constraint for studying changes and patterns of mortality disparities by education in Denmark and Sweden. The missing educational distribution of population also restricts analyses aiming at estimating contributions of compositional change to the improvements in national longevity. This study proposes a transparent approach to solve the two methodological issues allowing to obtain robust education-specific mortality estimates and population weights. METHODS: Using nonparametric approach, we redistribute the unknown cases and extrapolate the mortality curves of these sub-populations with the help of population-level data on an aggregate level from the Human Mortality Database. RESULTS: We present reconstructed and harmonized education-specific abridged and complete life tables for Sweden and Denmark covering 5-year-long periods from 1991-1995 to 2011-2015. The newly estimated life tables are in good agreement with the national life tables and show plausible age- and education-specific patterns. The observed changes in life expectancy by education suggest about the widening longevity gap between the highest and lowest educated for males and females in both countries. CONCLUSIONS: The proposed simple and transparent method can be applied in similar country-specific cases showing large proportions of missing education or other socio-economic characteristics at older ages.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Disability pension among persons with chronic disease: Differential impact of a Danish policy reform.

BACKGROUND: In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type. METHODS: The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated. RESULTS: Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs. CONCLUSION: Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

Determinants of inequalities in years with disability: an international-comparative study.

BACKGROUND: Persons with a lower socioeconomic position spend more years with disability, despite their shorter life expectancy, but it is unknown what the important determinants are. This study aimed to quantify the contribution to educational inequalities in years with disability of eight risk factors: father's manual occupation, low income, few social contacts, smoking, high alcohol consumption, high body-weight, low physical exercise and low fruit and vegetable consumption. METHODS: We collected register-based mortality and survey-based disability and risk factor data from 15 European countries covering the period 2010-14 for most countries. We calculated years with disability between the ages of 35 and 80 by education and gender using the Sullivan method, and determined the hypothetical effect of changing the prevalence of each risk factor to the prevalence observed among high educated ('upward levelling scenario'), using Population Attributable Fractions. RESULTS: Years with disability among low educated were higher than among high educated, with a difference of 4.9 years among men and 5.5 years among women for all countries combined. Most risk factors were more prevalent among low educated. We found the largest contributions to inequalities in years with disability for low income (men: 1.0 year; women: 1.4 year), high body-weight (men: 0.6 year; women: 1.2 year) and father's manual occupation (men: 0.7 year; women: 0.9 year), but contributions differed by country. The contribution of smoking was relatively small. CONCLUSIONS: Disadvantages in material circumstances (low income), circumstances during childhood (father's manual occupation) and high body-weight contribute to inequalities in years with disability.

Trends in health inequalities in 27 European countries.

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Occupational inequality in health expectancy in Denmark.

Background: The pension age in Denmark is adjusted in line with projected increasing life expectancy without taking health differentials between occupational groups into account. The purpose was to study occupational disparities in partial life expectancy and health expectancy between the ages of 50 and 75. Methods: Register data on occupation and mortality were combined with data from the Danish part of Survey of Health, Ageing and Retirement in Europe in 2010-2014 (N=3179). Expected lifetime without and with activity limitations and without and with long-term illness was estimated by Sullivan's method and comparisons made between four occupational groups. Results: We found clear differences between occupational groups. Expected lifetime without activity limitations between the ages of 50 and 75 was about 4.5 years longer for men and women in high skilled white-collar occupations than for men and women in low skilled blue-collar occupations. Men in high skilled blue-collar and low skilled white-collar occupations could expect 2.3 and 3.8 years shorter lifetimes without activity limitations, respectively, than men in high skilled white-collar occupations. For women in low skilled white-collar occupations, lifetime without activity limitations was 2.6 years shorter than for women in high skilled white-collar occupations. Due to few observations, no results were obtained for women in the high skilled blue-collar group. The social gradient was also significant when health was measured by years without long-term illness. Conclusions: The results support implementation of a flexible pension scheme to take into account the health differentials between occupational groups.

A health inequality impact assessment from reduction in overweight and obesity.

BACKGROUND: In recent years, social differences in overweight and obesity (OWOB) have become more pronounced. Health impact assessments provide population-level scenario evaluations of changes in disease prevalence and risk factors. The objective of this study was to simulate the health effects of reducing the prevalence of overweight and obesity in populations with short and medium education. METHODS: The DYNAMO-HIA tool was used to conduct a health inequality impact assessment of the future reduced disease prevalence (ischemic heart disease (IHD), diabetes, stroke, and multi-morbidity) and changes in life expectancy for the 2040-population of Copenhagen, Denmark (n = 742,130). We simulated an equalized weight scenario where the prevalence of OWOB in the population with short and medium education was reduced to the levels of the population with long education. RESULTS: A higher proportion of the population with short and medium education were OWOB relative to the population with long education. They also had a higher prevalence of cardiometabolic diseases. In the equalized weight scenario, the prevalence of diabetes in the population with short education was reduced by 8-10% for men and 12-13% for women. Life expectancy increased by one year among women with short education. Only small changes in prevalence and life expectancy related to stroke and IHD were observed. CONCLUSION: Reducing the prevalence of OWOB in populations with short and medium education will reduce the future prevalence of cardiometabolic diseases, increase life expectancy, and reduce the social inequality in health. These simulations serve as reference points for public health debates.

The effect of smoking on the healthy life expectancy of Palestinian men in the West Bank: a cross-sectional study.

BACKGROUND: The high prevalence of smoking (40%) in men living in the West Bank of the occupied Palestinian territory is a major challenge for the Palestinian health authorities. The aim of this study was to estimate life expectancy and the average lifetime with and without chronic disease in men living in the West Bank who had never smoked, were ex-smokers, or were smokers. METHODS: We used a life table for the male population in the West Bank and Danish relative risk estimates for death for smokers and ex-smokers versus never smokers and data from the 2010 Palestinian Family Survey. We estimated expected life time with and without chronic disease, and the contributions from the mortality and morbidity effects to smoking-related differences in average lifetime with and without chronic disease were assessed by decomposition. FINDINGS: The life expectancy of a Palestinian man aged 15 years who would never start smoking was 59·5 years, of which 41·1 years (95% CI 40·3-41·9) were expected to be without chronic disease. Ex-smokers could expect 57·9 years of remaining life time, 37·7 years (35·9-39·4) of which would be without chronic disease. For life-long heavy smokers, the expected lifetime was 52·6 years, of which 38·5 years (37·3-39·7) would be without chronic disease. Of the total loss of 6·9 years of life expectancy in heavy smokers, the mortality effect accounted for 2·5 years without disease and 4·4 years with disease, whereas the morbidity effect was negligible. The morbidity component of the decomposition accounted for 1·7 years with disease for moderate smokers and 2·9 years without disease for ex-smokers. INTERPRETATION: The high prevalence of smoking causes a considerable loss of life-years and life time without chronic disease. We recommend that the Palestinian health authorities enforce an anti-smoking law. FUNDING: None.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015.

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Ageing populations in the Nordic countries: Mortality and longevity from 1990 to 2014.

Aims: Cross-country comparisons of mortality and longevity patterns of Nordic populations could contribute with novel insights into the compositional changes of these populations. We investigated three metrics of population ageing: the proportion of the population aged 75+ and 90+ years, the proportion of birth cohorts reaching 75 and 90 years, and life expectancy (LE) at age 75 and 90 years in Sweden, Norway, Iceland, Denmark and Finland, in the period 1990-2014. Methods: Demographic information was collected from national statistical databases and the Human Mortality Database. Results: All metrics on population ageing increased during the study period, but there were some cross-country variations. Finland experienced a notably steep increase in the proportion of 75+ and 90+ year olds compared to the other countries. Regarding the proportion reaching old ages, the Finnish lagged behind from the beginning, but females decreased this difference. The Danes were more similar to the other countries at the beginning, but did not experience the same increase over time. Gender-specific LE at age 75 and 90 years was similar overall in the five countries. Conclusions: Developments in cross-country variation suggest that survival until old age has become more similar for Finnish females and more different for Danish males and females compared with the other countries in recent decades. This provides perspectives on the potential to improve longevity in Denmark and Finland. Similarities in LE in old age suggest that expected mortality in old age has been more similar throughout the study period.

Inequalities in employment rates among older men and women in Canada, Denmark, Sweden and the UK.

BACKGROUND: In most developed countries, governments are implementing policies encouraging older persons to work past 65 years to reduce the burden on societies related to disability benefits and pension payments. Despite this push to extend working lives, we know little about who already works past this age and any inequalities that may exist. Our study investigates the employment rates of those aged 65-75 years of age by educational level, health status and sex in Canada (CAN), Denmark (DK), Sweden (SE) and the United Kingdom (UK). Secondly, we aim to relate findings on employment rates to prevailing policies in the different countries, to increase the understanding on how to further extend working lives. METHODS: We used nationally representative cross-sectional survey data from the 2012-2013 Canadian Community Health Survey, 2013/14 Survey of Health, Ageing and Retirement in Europe for Denmark and Sweden and the 2013 English Longitudinal Study of Ageing to examine employment rates for those aged 65-75 years by sex, educational level and health status (having limiting longstanding illness (LLI) or not). RESULTS: Employment rates decline by age, but we see a linear decline in CAN and the UK compared to an initial decline then a plateau of employment rates from 66 to 68 years in DK and SE. Employment rates among persons aged 65-75 years were lower in the UK than in CAN, DK and SE. Among women, employment rates were highest in SE. Women with low education and a LLI had considerably lower employment rates than men with low education and a LLI (employment rates for men ranged from 27% to 12% compared with employment rates for women which ranged from 12% to 0%). CONCLUSIONS: Our results suggest that educational level, sex and health all play a role in extending working lives. The variation in employment rates between the four countries implies that policies do matter, but that social differentials show that policies cannot be 'one size fits all'. Policy-makers must consider different groups (i.e. low-educated women with a LLI) when designing policies to extend working lives.

The impact of smoking on expected lifetime with and without chronic disease among Palestinian men in the West Bank.

Background: The purpose of the study was to estimate life expectancy and the average lifetime with and without chronic disease among male never smokers, ex-smokers and smokers living in the West Bank of the occupied Palestinian territory. Methods: The study used a life table for the West Bank male population and Danish relative risk estimates for death for smokers and ex-smokers vs. never smokers and utilized data from the Palestinian Family Survey 2010. Expected lifetime with and without chronic disease was estimated and the contributions from the mortality and the morbidity effect to smoking related difference in average lifetime with and without chronic disease were assessed by decomposition. Results: In the West bank 40% of the male population are smokers. Life expectancy of 15-year-old Palestinian men who would never start smoking was 59.5 years, 41.1 of which were expected to be without chronic disease. Ex-smokers could expect 57.9 years of remaining lifetime, 37.7 years of which without disease. For lifelong heavy smokers (> 20 cigarettes per day), the expected lifetime was reduced to 52.6 years, of which 38.5 years were without chronic disease. Of the total loss of 6.9 years of life expectancy among heavy smokers, the mortality effect accounted for 2.5 years without and 4.4 years with disease, whereas the morbidity effect was negligible. Conclusions: The high prevalence of smoking causes a considerable loss of life years and lifetime without chronic disease. We recommend the Palestinian health authorities to enforce the anti-smoking law.

Socio-demographic determinants and effect of structured personal diabetes care: a 19-year follow-up of the randomized controlled study diabetes Care in General Practice (DCGP).

BACKGROUND: We investigated how four aspects of socio-demography influence the effectiveness of an intervention with structured personal diabetes care on long-term outcomes. METHODS: The Diabetes Care in General Practice (DCGP) study is a cluster-randomized trial involving a population-based sample of 1381 patients with newly diagnosed type 2-diabetes mellitus. We investigated how education, employment, cohabitation status and residence influenced the effectiveness of 6 years of intervention with structured personal diabetes care, resembling present day recommendations. Outcomes were incidence of any diabetes-related endpoint and death during 19 years after diagnosis, and cardiovascular risk factors, behaviour, attitudes and process-of-care variables 6 years after diagnosis. RESULTS: Structured personal care reduced the risk of any diabetes-related endpoint and the effect of the intervention was modified by geographical area (interaction p = 0.034) with HR of 0.71 (95%CI: 0.60-0.85) and of 1.07 (95%CI: 0.77-1.48), for patients in urban and rural areas, respectively. Otherwise, there was no effect modification of education, employment and civil status on the intervention for the final endpoints. There were no noticeable socio-demographic differences in the effect of the intervention on cardiovascular risk factors, behaviour, attitudes, and process-of-care. CONCLUSION: Structured personal care reduced the aggregate outcome of any diabetes-related endpoint and independent of socio-demographic factors similar effect on cardiovascular risk factors, behaviour, attitudes and process of care, but the intervention did not change the existing inequity in mortality and morbidity. Residence modified the uptake of the intervention with patients living in urban areas having more to gain of the intervention than rural patients, further investigations is warranted. TRIAL REGISTRATION: ClinicalTrials.gov registration no. NCT01074762 (February 24, 2010).

Persistent social inequality in life expectancy and disability-free life expectancy: Outlook for a differential pension age in Denmark?

AIMS: The state old-age pension in Denmark increases to keep pace with the projected increase in average life expectancy (LE) without any regard to the social gap in LE and expected lifetime in good health. The purpose of this study was to compare changes in LE and disability-free life expectancy (DFLE) between groups of Danes with high, medium and low levels of education. METHODS: Nationwide register data on education and mortality were combined with data from the Surveys of Health, Ageing and Retirement in Europe (SHARE) surveys in 2006-2007, 2010-2011 and 2013-2014 and the DFLE by educational level was estimated by Sullivan's method for each of these three time points. RESULTS: Between 2006-2007 and 2013-2014, LE among 65-year-old men and women with a low educational level increased by 1.3 and 1.0 years, respectively, and by 1.4 and 1.3 years for highly educated men and women. The gap in LE between people with high and low levels of education remained more than 2 years. In 2006-2007, 65-year-old men with a high level of education could expect 3.2 more years without disability than men of the same age with a low level of education. In 2013-2014, the difference was 2.9 years. For women, the results were 3.7 and 3.4 years, respectively. CONCLUSIONS: With the persistent social inequality in LE of more than 2 years and the continuous gap between high and low educational groups in DFLE of about 3 years, a differential pension age is recommended.

Improvement in health expectancy at ages 50 and 65 in Denmark during the period 2004-2011.

AIMS: In Denmark life expectancy (LE) has increased since 1995 after a long period of stagnation. Healthy life expectancy (HLE) at age 65 increased more than LE during the period 1987-2005. The aim of the study was to determine the trend in HLE in Denmark at ages 50 and 65 during the period 2004-2011. METHODS: The study was based on nationwide register data on mortality and data on health status from the SHARE surveys carried out in 2004/2005, 2006/2007 and 2010/2011. Expected lifetime in various health states was estimated by Sullivan's method. Changes from 2004 to 2011 were decomposed into contributions from changes in mortality and prevalence of activity limitations. RESULTS: During the period 2004-2011 LE increased by about 1 year at both age 50 and age 65. However, the increase in expected lifetime in self-rated good health, without long-term health problems and without activity limitations was even longer in both genders and it increased by 1.5-4.0 years depending on age, gender and health indicator. Consequently, expected lifetime in an unhealthy state decreased and the proportions of lifetime in a healthy state increased. The disability effect of the health gain was stronger than the mortality effect. CONCLUSIONS: In Denmark HLE increased substantially more than LE during the period 2004-2011 for all three health indicators at both age 50 and age 65, and for both genders. Thus, the improvement in health expectancy continued in Denmark in recent years.

Gender-specific modifying effect on the educational disparities in the impact of smoking on health expectancy.

BACKGROUND: Smoking reduces life years in good health but it is unclear how education modifies the impact of smoking. We hypothesize that the vulnerability of the effect of smoking on health expectancy decreases with educational level in both genders and examine the contributions of mortality and health effects. METHODS: Life tables by educational level and smoking category were constructed from registers and survey data. For each educational level, difference in expected lifetime in self-rated good and poor health between 30-year-old never smokers and smokers were estimated and decomposed into contributions from mortality and health status. RESULTS: Difference in expected lifetime in good health between never smokers and smokers decreased with educational level for women but increased for men. Thus, the differences between never smokers and heavy smokers among 30-year-old women with a low, medium and high educational level were 12.9, 8.9 and 4.1 years, respectively. In contrast, the differences between male never smokers and heavy smokers with a low, medium and high educational level were 10.3, 11.4 and 14.3 years, respectively. Regardless of educational level, the mortality effect increased by exposure to smoking but the effect of health status increased by educational level for men and decreased for women. CONCLUSION: The social differential vulnerability to the effect of smoking differed between genders. Thus, whereas smoking had a substantial effect on health among women with a low educational level the pattern for men was opposite because the health gain for never smokers was greatest for men with a high education.

Increasing disability-free life expectancy among older adults in Palestine from 2006 to 2010.

BACKGROUND: The population of Palestine comprises almost 200 000 Palestinians aged 60 or older. The purpose of the study was to estimate disability-free life expectancy for Palestinians living in the West Bank and Gaza Strip and to evaluate changes from 2006 to 2010. METHODS: The study combined mortality data and prevalence of activity limitation derived from the Palestinian Family Health Surveys carried out in 2006 and 2010. Based on questions about the ability to perform five basic daily activities, disability-free life expectancy was estimated. Changes between 2006 and 2010 were decomposed into contributions from changes in mortality and disability. RESULTS: Life expectancy at age 60 increased from 17.1 years in 2006 to 17.3 years in 2010 for men and from 18.7 years to 19.0 years for women. Disability-free life expectancy increased significantly, by 1.3 years for 60-year-old men (from 12.8 years to 14.1 years) and 1.8 years for 60-year-old women (from 12.6 years to 14.4 years). This increase was seen in the Gaza Strip as well as in the West Bank. While the modest contribution of the mortality effect did not differ between gender and regions, the strong contributions from the disability effects varied, being greatest for women in the Gaza Strip. CONCLUSION: The significant increase in disability-free life expectancy for both genders is remarkable and, to our knowledge, not seen in other low-income countries. This change may be due to decreasing incidence of disability and greater recovery from disability as a result of better prevention, care and rehabilitation of chronic diseases.