[Use of Roll Your Own Tobacco in the Basque Country: magnitude, socio-economic inequalities and evolution in the period 2013-2018]. / Consumo de tabaco de liar en el País Vasco: magnitud, desigualdades socioeconómicas y evolución en el periodo 2013-2018.

OBJECTIVE: Despite the global reduction in smoking, the consumption of roll-your-own tobacco has increased in recent years in many countries, which may be slowing down the downward trend in smoking. The aim of this paper was to analyse the evolution of the number of people who use roll-your-own tobacco and tobacco of any type between 2013 and 2018 in the Basque Country and measure whether there were socioeconomic inequalities in its consumption. METHODS: We carried out an observational and cross-sectional study of a representative sample of the population living in the Basque Country aged 16 to 59 years (n2013=6929 y n2018=7961) from the Basque Health Survey (2013 and 2018) and the Basque Addictions Survey (2018). We calculated prevalences of regular tobacco smoking in general and of roll-your-own cigarettes according to different socioeconomic variables for the years 2013 and 2018, as well as prevalence ratios for the estimation of change between these years and according to the above variables through robust Poisson regression models. We stratified analyses by sex and two age groups. RESULTS: Overall smoking prevalence decreased between 2013 (men=27.7% and women=24.1%) and 2018 but remained the same for those who used roll-your-own tobacco (in 2013, men=5.1% and women=3.2%; in 2018=5.4% and 3.5%, respectively). In contrast to tobacco in general, which showed a clear socio-economic gradient, roll-your-own tobacco use was more prevalent among young people (in 2018, men=6.4% and women=4.1%), a group where the pattern by socio-economic status was less evident. CONCLUSIONS: Considering the persistence of roll-your-own tobacco consumption, we also should direct tobacco control towards this kind of product, and its use should be monitored and supervised, especially among young people.

OBJECTIVE: A pesar de la reducción del número de personas fumadoras a nivel mundial, el consumo de tabaco de liar ha aumentado en los últimos años en muchos países, lo que puede frenar la tendencia descendente del hábito tabáquico. El objetivo de este trabajo fue analizar la evolución del número de personas que consumen tabaco de liar y tabaco de cualquier tipo entre 2013 y 2018 en el País Vasco y determinar si existían desigualdades socioeconómicas en su consumo. METHODS: Se realizó un estudio observacional y transversal de una muestra representativa de la población residente en el País Vasco de dieciséis a cincuenta y nueve años (n2013=6.929 y n2018=7.961) a partir de la Encuesta de Salud del País Vasco (años 2013 y 2018) y de la Encuesta sobre Adicciones de Euskadi (2018). Se calcularon las prevalencias de consumo habitual de tabaco en general y de tabaco de liar según diferentes variables socioeconómicas para los años 2013 y 2018, así como las razones de prevalencia para la estimación del cambio entre esos años y según las variables anteriores mediante modelos de regresión de Poisson robusto. Los análisis se estratificaron por sexo y por dos grupos de edad. RESULTS: La prevalencia de consumo de tabaco en general disminuyó entre 2013 (hombres=27,7% y mujeres=24,1%) y 2018 (hombres=24,1% y mujeres=18,6%), pero se mantuvo en el caso del consumo de tabaco de liar (en 2013, hombres=5,1% y mujeres=3,2%; en 2018, 5,4% y 3,5%, respectivamente). A diferencia del consumo de tabaco en general, que presentó un claro gradiente socioeconómico, el consumo de tabaco de liar fue más prevalente entre las personas jóvenes (en 2018, hombres=6,4% y mujeres=4,1%), grupo en el que el patrón por posición socioeconómica era menos evidente. CONCLUSIONS: Considerando la persistencia en el consumo de tabaco de liar, es preciso dirigir también la lucha contra el tabaquismo hacia este tipo de productos, así como vigilar y monitorizar su consumo, especialmente entre las personas jóvenes.

Consumo de tabaco de liar en el País Vasco: magnitud, desigualdades socioeconómicas y evolución en el periodo 2013-2018 / Use of Roll Your Own Tobacco in the Basque Country: magnitude, socio-economic inequalities and evolution in the period 2013-2018

Fundamentos: A pesar de la reducción del número de personas fumadoras a nivel mundial, el consumo de tabaco de liar ha aumentado en los últimos años en muchos países, lo que puede frenar la tendencia descendente del hábito tabáquico. El objetivo de este trabajo fue analizar la evolución del número de personas que consumen tabaco de liar y tabaco de cualquier tipo entre 2013 y 2018 en el País Vasco y determinar si existían desigualdades socioeconómicas en su consumo. Métodos: Se realizó un estudio observacional y transversal de una muestra representativa de la población residente en el País Vasco de dieciséis a cincuenta y nueve años (n 2013=6.929 y n 2018=7.961) a partir de la Encuesta de Salud del País Vasco (años 2013 y 2018) y de la Encuesta sobre Adicciones de Euskadi (2018). Se calcularon las prevalencias de consumo habitual de tabaco en general y de tabaco de liar según diferentes variables socioeconómicas para los años 2013 y 2018, así como las razones de prevalencia para la estimación del cambio entre esos años y según las variables anteriores mediante modelos de regresión de Poisson robusto. Los análisis se estratificaron por sexo y por dos grupos de edad. RESULTADOS // La prevalencia de consumo de tabaco en general disminuyó entre 2013 (hombres=27,7% y mujeres=24,1%) y 2018 (hombres=24,1% y mujeres=18,6%), pero se mantuvo en el caso del consumo de tabaco de liar (en 2013, hombres=5,1% y mujeres=3,2%; en 2018, 5,4% y 3,5%, respectivamente). A diferencia del consumo de tabaco en general, que presentó un claro gradiente socioeconómico, el consumo de tabaco de liar fue más prevalente entre las personas jóvenes (en 2018, hombres=6,4% y mujeres=4,1%), grupo en el que el patrón por posición socioeconómica era menos evidente. Conclusiones: Considerando la persistencia en el consumo de tabaco de liar, es preciso dirigir también la lucha contra el tabaquismohacia...(AU)

Background: Despite the global reduction in smoking, the consumption of roll-your-own tobacco has increased in recent years in many countries, which may be slowing down the downward trend in smoking. The aim of this paper was to analyse the evolution of the number of people who use roll-your-own tobacco and tobacco of any type between 2013 and 2018 in the Basque Country and measure whether there were socioeconomic inequalities in its consumption. Methods: We carried out an observational and cross-sectional study of a representative sample of the population living in the Basque Country aged 16 to 59 years (n2013=6929 y n2018=7961) from the Basque Health Survey (2013 and 2018) and the Basque Addictions Survey (2018). We calculated prevalences of regular tobacco smoking in general and of roll-your-own cigarettes according to different socioeconomic variables for the years 2013 and 2018, as well as prevalence ratios for the estimation of change between these years and according to the above variables through robust Poisson regression models. We stratified analyses by sex and two age groups.Results: Overall smoking prevalence decreased between 2013 (men=27.7% and women=24.1%) and 2018 but remained the same for those who used roll-your-own tobacco (in 2013, men=5.1% and women=3.2%; in 2018=5.4% and 3.5%, respectively). In contrast to tobacco in general, which showed a clear socio-economic gradient, roll-your-own tobacco use was more prevalent among young people (in 2018, men=6.4% and women=4.1%), a group where the pattern by socio-economic status was less evident.Conclusions: Considering the persistence of roll-your-own tobacco consumption, we also should direct tobacco control towards this kind of product, and its use should be monitored and supervised, especially among young people.(AU)

Decomposition of Differentials in Health Expectancies From Multistate Life Tables: A Research Note.

Multistate modeling is a commonly used method to compute healthy life expectancy. However, there is currently no analytical method to decompose the components of differentials in summary measures calculated from multistate models. In this research note, we propose a derivative-based method to decompose the differentials in population-based health expectancies estimated via a multistate model into two main components: the proportion resulting from differences in initial health structure and the proportion resulting from differences in health transitions. We illustrate the method using data on activities of daily living from the U.S. Health and Retirement Study to decompose the sex differential in disability-free life expectancy (HLE) among older Americans. Our results suggest that the sex gap in HLE results primarily from differences in transition rates between disability states rather than from the initial health distribution of female and male populations. The methods introduced here will enable researchers, including those working in fields other than health, to decompose the relative contribution of initial population structure and transition probabilities to differences in state-specific life expectancies from multistate models.

A global assessment of the impact of violence on lifetime uncertainty.

Uncertainty around age at death, or lifetime uncertainty, is a key public health indicator and a marker of inequality in survival. How does the extent of violence affect lifetime uncertainty? We address this question by quantifying the impact of violence on dispersion in the ages at death, the metric most used to measure lifetime uncertainty. Using mortality data from the Global Burden of Disease Study and the Internal Peace Index between 2008 and 2017, we find that the most violent countries are also those with the highest lifetime uncertainty. In the Middle East, conflict-related deaths are the largest contributor to lifetime uncertainty. In Latin America, a similar pattern is attributable to homicides. The effects are larger in magnitude for men, but the consequences remain considerable for women. Our study points to a double burden of violence on longevity: Not only does violence shorten individual lives, but it also makes the length of life less predictable.

Sex differences in the mortality rate for coronavirus disease 2019 compared to other causes of death: an analysis of population-wide data from 63 countries.

Men are more likely than women to die due to coronavirus disease 2019 (COVID-19). An open question is whether these sex differences reflect men's generally poorer health and lower life expectancy compared to women of similar ages or if men face a unique COVID-19 disadvantage. Using age-specific data on COVID-19 mortality as well as cause-specific and all-cause mortality for 63 countries, we compared the sex difference in COVID-19 mortality to sex differences in all-cause mortality and mortality from other common causes of death to determine the magnitude of the excess male mortality disadvantage for COVID-19. We found that sex differences in the age-standardized COVID-19 mortality rate were substantially larger than for the age-standardized all-cause mortality rate and mortality rate for most other common causes of death. The excess male mortality disadvantage for COVID-19 was especially large in the oldest age groups. Our findings suggest that the causal pathways that link male sex to a higher mortality from a SARS-CoV-2 infection may be specific to SARS-CoV-2, rather than shared with the pathways responsible for the shorter life expectancy among men or sex differences for other common causes of death. Understanding these causal chains could assist in the development of therapeutics and preventive measures for COVID-19 and, possibly, other coronavirus diseases.

Years of life lost to COVID-19 in 81 countries.

Understanding the mortality impact of COVID-19 requires not only counting the dead, but analyzing how premature the deaths are. We calculate years of life lost (YLL) across 81 countries due to COVID-19 attributable deaths, and also conduct an analysis based on estimated excess deaths. We find that over 20.5 million years of life have been lost to COVID-19 globally. As of January 6, 2021, YLL in heavily affected countries are 2-9 times the average seasonal influenza; three quarters of the YLL result from deaths in ages below 75 and almost a third from deaths below 55; and men have lost 45% more life years than women. The results confirm the large mortality impact of COVID-19 among the elderly. They also call for heightened awareness in devising policies that protect vulnerable demographics losing the largest number of life-years.

Monitoring life expectancy levels during the COVID-19 pandemic: Example of the unequal impact of the first wave on Spanish regions.

BACKGROUND: To provide an interpretable summary of the impact on mortality of the COVID-19 pandemic we estimate weekly and annual life expectancies at birth in Spain and its regions. METHODS: We used daily death count data from the Spanish Daily Mortality Monitoring System (MoMo), and death counts from 2018, and population on July 1st, 2019 by region (CCAA), age groups, and sex from the Spanish National Statistics Institute. We estimated weekly and annual (2019 and 2020*, the shifted annual calendar period up to 5 July 2020) life expectancies at birth as well as their differences with respect to 2019. RESULTS: Weekly life expectancies at birth in Spain were lower in weeks 11-20, 2020 compared to the same weeks in 2019. This drop in weekly life expectancy was especially strong in weeks 13 and 14 (March 23rd to April 5th), with national declines ranging between 6.1 and 7.6 years and maximum regional weekly declines of up to 15 years in Madrid. Annual life expectancy differences between 2019 and 2020 also reflected an overall drop in annual life expectancy of 0.9 years for both men and women. These drops ranged between 0 years in several regions (e.g. Canary and Balearic Islands) to 2.8 years among men in Madrid. CONCLUSIONS: Life expectancy is an easy to interpret measure for understanding the heterogeneity of mortality patterns across Spanish regions. Weekly and annual life expectancy are sensitive and useful indicators for understanding disparities and communicating the gravity of the situation because differences are expressed in intuitive year units.

Monitoring trends and differences in COVID-19 case-fatality rates using decomposition methods: Contributions of age structure and age-specific fatality.

The population-level case-fatality rate (CFR) associated with COVID-19 varies substantially, both across countries at any given time and within countries over time. We analyze the contribution of two key determinants of the variation in the observed CFR: the age-structure of diagnosed infection cases and age-specific case-fatality rates. We use data on diagnosed COVID-19 cases and death counts attributable to COVID-19 by age for China, Germany, Italy, South Korea, Spain, the United States, and New York City. We calculate the CFR for each population at the latest data point and also for Italy, Germany, Spain, and New York City over time. We use demographic decomposition to break the difference between CFRs into unique contributions arising from the age-structure of confirmed cases and the age-specific case-fatality. In late June 2020, CFRs varied from 2.2% in South Korea to 14.0% in Italy. The age-structure of detected cases often explains more than two-thirds of cross-country variation in the CFR. In Italy, the CFR increased from 4.2% to 14.0% between March 9 and June 30, 2020, and more than 90% of the change was due to increasing age-specific case-fatality rates. The importance of the age-structure of confirmed cases likely reflects several factors, including different testing regimes and differences in transmission trajectories; while increasing age-specific case-fatality rates in Italy could indicate other factors, such as the worsening health outcomes of those infected with COVID-19. Our findings lend support to recommendations for data to be disaggregated by age, and potentially other variables, to facilitate a better understanding of population-level differences in CFRs. They also show the need for well-designed seroprevalence studies to ascertain the extent to which differences in testing regimes drive differences in the age-structure of detected cases.

The increasing lifespan variation gradient by area-level deprivation: A decomposition analysis of Scotland 1981-2011.

Life expectancy inequalities are an established indicator of health inequalities. More recent attention has been given to lifespan variation, which measures the amount of heterogeneity in age at death across all individuals in a population. International studies have documented diverging socioeconomic trends in lifespan variation using individual level measures of income, education and occupation. Despite using different socioeconomic indicators and different indices of lifespan variation, studies reached the same conclusion: the most deprived experience the lowest life expectancy and highest lifespan variation, a double burden of mortality inequality. A finding of even greater concern is that relative differences in lifespan variation between socioeconomic group were growing at a faster rate than life expectancy differences. The magnitude of lifespan variation inequalities by area-level deprivation has received limited attention. Area-level measures of deprivation are actively used by governments for allocating resources to tackle health inequalities. Establishing if the same lifespan variation inequalities emerge for area-level deprivation will help to better inform governments about which dimension of mortality inequality should be targeted. We measure lifespan variation trends (1981-2011) stratified by an area-level measure of socioeconomic deprivation that is applicable to the entire population of Scotland, the country with the highest level of variation and one of the longest, sustained stagnating trends in Western Europe. We measure the gradient in variation using the slope and relative indices of inequality. The deprivation, age and cause specific components driving the increasing gradient are identified by decomposing the change in the slope index between 1981 and 2011. Our results support the finding that the most advantaged are dying within an ever narrower age range while the most deprived are facing greater and increasing uncertainty. The least deprived group show an increasing advantage, over the national average, in terms of deaths from circulatory disease and external causes.

Changing contribution of area-level deprivation to total variance in age at death: a population-based decomposition analysis.

OBJECTIVES: Two processes generate total variance in age at death: heterogeneity (between-group variance) and individual stochasticity (within-group variance). Limited research has evaluated how these two components have changed over time. We quantify the degree to which area-level deprivation contributed to total variance in age at death in Scotland between 1981 and 2011. DESIGN: Full population and mortality data for Scotland were obtained and matched with the Carstairs score, a standardised z-score calculated for each part-postcode sector that measures relative area-level deprivation. A z-score above zero indicates that the part-postcode sector experienced higher deprivation than the national average. A z-score below zero indicates lower deprivation. From the aggregated data we constructed 40 lifetables, one for each deprivation quintile in 1981, 1991, 2001 and 2011 stratified by sex. PRIMARY OUTCOME MEASURES: Total variance in age at death and the proportion explained by area-level deprivation heterogeneity (between-group variance). RESULTS: The most deprived areas experienced stagnating or slightly increasing variance in age at death. The least deprived areas experienced decreasing variance. For males, the most deprived quintile life expectancy was between 7% and 11% lower and the SD is between 6% and 25% higher than the least deprived. This suggests that the effect of deprivation on the SD of longevity is comparable to its effect on life expectancy. Decomposition analysis revealed that contributions from between-group variance doubled between 1981 and 2011 but at most only explained 4% of total variance. CONCLUSIONS: This study adds to the emerging body of literature demonstrating that socio-economic groups have experienced diverging trends in variance in age at death. The contribution from area-level deprivation to total variance in age at death, which we were able to capture, has doubled since 1981. Area-level deprivation may play an increasingly important role in mortality inequalities.

Trends in avoidable mortality over the life course in Mexico, 1990-2015: a cross-sectional demographic analysis.

OBJECTIVE: To analyse average lifespan and quantify the effect of avoidable/amenable mortality on the difference between state-specific mortality and a low-mortality benchmark in Mexico during 1990-2015. DESIGN: Retrospective cross-sectional demographic analysis using aggregated data. SETTING: Vital statistics from the Mexican civil registration system. PARTICIPANTS: Aggregated national data (from 91.2 million people in 1995 to 119.9 in 2015) grouped in 64 populations (32 Mexican states (including Mexico City) by sex) with cause-of-death data. MAIN OUTCOME MEASURES: Cause-specific contributions to the gap in life expectancy with a low-mortality benchmark in three age groups (0-14, 15-49 and 50-84 years). RESULTS: Infants and children under the age of 15 years show improvements towards maximal survival in all states. However, adult males aged 15 to 49 years show deterioration after 2006 in almost every state due to increasing homicides, and a slow recovery thereafter. Out of 35 potential years, females and males live on average 34.57 (34.48 to 34.67) and 33.80 (33.34 to 34.27), respectively. Adults aged 50 to 84 years show an unexpected decrease in the low mortality benchmark, indicating nationwide deterioration among older adults. Females and males in this age group show an average survival of 28.59 (27.43 to 29.75) and 26.52 (25.33 to 27.73) out of 35 potential years, respectively. State gaps from the benchmark were mainly caused by ischaemic heart diseases, diabetes, cirrhosis and homicides. We find large health disparities between states, particularly for the adult population after 2005. CONCLUSIONS: Mexico has succeeded in reducing mortality and between-state inequalities in children. However, adults are becoming vulnerable as they have not been able to reduce the burden of violence and conditions amenable to health services and behaviours, such as diabetes, ischaemic heart diseases and cirrhosis. These trends have led to large health disparities between Mexican states in the last 25 years.

A Cause-of-Death Decomposition of Young Adult Excess Mortality.

We propose a method to decompose the young adult mortality hump by cause of death. This method is based on a flexible shape decomposition of mortality rates that separates cause-of-death contributions to the hump from senescent mortality. We apply the method to U.S. males and females from 1959 to 2015. Results show divergence between time trends of hump and observed deaths, both for all-cause and cause-specific mortality. The study of the hump shape reveals age, period, and cohort effects, suggesting that it is formed by a complex combination of different forces of biological and socioeconomic nature. Male and female humps share some traits in all-cause shape and trend, but they also differ by their overall magnitude and cause-specific contributions. Notably, among males, the contributions of traffic and other accidents were progressively replaced by those of suicides, homicides, and poisonings; among females, traffic accidents remained the major contributor to the hump.

A unified framework of demographic time.

Demographic thought and practice is largely conditioned by the Lexis diagram, a two-dimensional graphical representation of the identity between age, period, and birth cohort. This relationship does not account for remaining years of life, total length of life, or time of death, whose use in demographic research is both underrepresented and incompletely situated. We describe an identity between these six demographic time measures and describe the sub-identities and diagrams that pertain to this identity. We provide an application of this framework to the measurement of late-life morbidity prevalence. We generalize these relationships to higher order identities derived from an arbitrary number of events in calendar time. Our examples are based on classic human demography, but the concepts we present can reveal patterns and relationships in any event history data, and contribute to the study of human or non-human population dynamics measured on any scale of calendar time.