Poor people smoke more

Social status is intimately linked with health-related risk factors. In the current issue of Deutsches Ärzteblatt International, Thomas Lampert, of the Robert Koch Institute (RKI) in Berlin, inquires to what extent smoking, physical inactivity, and obesity are associated with social status (Dtsch Arztebl Int 2010; 107(1-2): 1-7).

The data for his investigation of social status-specific differences stemmed from the RKI's Telephone Health Survey. In interviews conducted with a total of 8318 individuals over a period of 18 years the RKI recorded interviewees' responses to questions regarding current smoking status, degree of physical activity, height, and weight. The subjects' social status was determined from their statements on education, occupation, and net household income. The analyses were also intended to reveal any age- and sex-specific variations.

Evaluation of the data showed that men of low social status are more likely to be smokers, to be physically inactive, and to be obese. The same goes for women, with an even stronger link with obesity.

Given that the risk factors smoking, physical inactivity, and obesity are connected with many chronic diseases, Lampert sees considerable potential for prevention and cost reduction.

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Numerous German and international studies indicate that the risk of illness and early death varies with social status and is highest among the lowest status groups . The diseases and causes of death that are distributed unequally according to social status include coronary heart disease, stroke, diabetes mellitus, chronic bronchitis, liver cirrhosis, and certain forms of cancer, e.g., lung cancer and bowel cancer. Many of these diseases are associated with risk factors that can be viewed in connection with the patient’s individual health behavior. Great importance is therefore attached to status-specific differences in health behavior in explaining unequal rates of illness and death.

For instance, the World Health Organization (WHO) assumes that more than half of the social differences in early mortality among men in industrialized countries can be attributed to the higher rates of smoking in the low status groups. Other factors thought to be responsible for the increased risk of illness and death in segments of the population with low social status are the lower rates of participation in sports and physical activity in general and the higher frequency of overweight and especially obesity.

In Germany, it was demonstrated empirically as early as the 1980s that persons of low social status smoke more commonly, have lower levels of physical and sporting activity, and are more often overweight or obese. Among other investigations, compelling findings emerged from the German Cardio vas cular Prevention Study (Deutsche Herz-Kreislauf- Präventionsstudie, DHP) and the MONICA Augsburg Study, both of which focused on cardiovascular diseases and risk factors. In recent years the nationwide health surveys conducted by the Robert Koch Institute (RKI) have played a leading role in providing robust basic data for analysis of the connection between social status and health and health behavior.