Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women.
In 2011, WHO member states signed up to the 25 × 25 initiative, a plan to cut mortality due to non-communicable diseases by 25% by 2025. However, socioeconomic factors influencing non-communicable diseases have not been included in the plan. In this study, we aimed to compare the contribution of socioeconomic status to mortality and years-of-life-lost with that of the 25 × 25 conventional risk factors.



We did a multicohort study and meta-analysis with individual-level data from 48 independent prospective cohort studies with information about socioeconomic status, indexed by occupational position, 25 × 25 risk factors (high alcohol intake, physical inactivity, current smoking, hypertension, diabetes, and obesity), and mortality, for a total population of 1 751 479 (54% women) from seven high-income WHO member countries. We estimated the association of socioeconomic status and the 25 × 25 risk factors with all-cause mortality and cause-specific mortality by calculating minimally adjusted and mutually adjusted hazard ratios [HR] and 95% CIs. We also estimated the population attributable fraction and the years of life lost due to suboptimal risk factors.



During 26·6 million person-years at risk (mean follow-up 13·3 years [SD 6·4 years]), 310 277 participants died. HR for the 25 × 25 risk factors and mortality varied between 1·04 (95% CI 0·98-1·11) for obesity in men and 2 ·17 (2·06-2·29) for current smoking in men. Participants with low socioeconomic status had greater mortality compared with those with high socioeconomic status (HR 1·42, 95% CI 1·38-1·45 for men; 1·34, 1·28-1·39 for women); this association remained significant in mutually adjusted models that included the 25 × 25 factors (HR 1·26, 1·21-1·32, men and women combined). The population attributable fraction was highest for smoking, followed by physical inactivity then socioeconomic status. Low socioeconomic status was associated with a 2·1-year reduction in life expectancy between ages 40 and 85 years, the corresponding years-of-life-lost were 0·5 years for high alcohol intake, 0·7 years for obesity, 3·9 years for diabetes, 1·6 years for hypertension, 2·4 years for physical inactivity, and 4·8 years for current smoking.



Socioeconomic circumstances, in addition to the 25 × 25 factors, should be targeted by local and global health strategies and health risk surveillance to reduce mortality.



European Commission, Swiss State Secretariat for Education, Swiss National Science Foundation, the Medical Research Council, NordForsk, Portuguese Foundation for Science and Technology.
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland. Electronic address: silvia.stringhini@chuv.ch.
Silvia
S
Stringhini
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Cristian
C
Carmeli
Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland.
Markus
M
Jokela
Department of Global Health and Social Medicine, King's College London, London, UK; Harvard T H Chan School of Public Health, Boston MA, USA.
Mauricio
M
Avendaño
Global Research Analytics for Population Health, Health Policy and Management, Columbia University, New York, NY, USA.
Peter
P
Muennig
MRC-PHE Centre for Environment and Health, School of Public Health, Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Florence
F
Guida
Epidemiology Unit, ASL TO3 Piedmont Region, Grugliasco, Italy.
Fulvio
F
Ricceri
Epidemiology Unit, ASL TO3 Piedmont Region, Grugliasco, Italy.
Angelo
A
d'Errico
EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal; Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal.
Henrique
H
Barros
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Murielle
M
Bochud
MRC-PHE Centre for Environment and Health, School of Public Health, Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Marc
M
Chadeau-Hyam
Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.
Françoise
F
Clavel-Chapelon
Department of Biological and Clinical Sciences, Universtiy of Turin, Turin, Italy.
Giuseppe
G
Costa
INSERM, UMR1027, Toulouse, France; Université Toulouse III Paul-Sabatier, UMR1027, Toulouse, France.
Cyrille
C
Delpierre
EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal.
Silvia
S
Fraga
Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France; Paris Descartes University, Paris, France.
Marcel
M
Goldberg
Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, VIC, Australia.
Graham G
GG
Giles
Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
Vittorio
V
Krogh
INSERM, UMR1027, Toulouse, France; Université Toulouse III Paul-Sabatier, UMR1027, Toulouse, France.
Michelle
M
Kelly-Irving
Department of Sociology, Trinity College Dublin, Dublin, Ireland.
Richard
R
Layte
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Aurélie M
AM
Lasserre
University College London, Department of Epidemiology and Public Health, London, UK.
Michael G
MG
Marmot
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Martin
M
Preisig
University College London, Department of Epidemiology and Public Health, London, UK.
Martin J
MJ
Shipley
Institute of Social and Preventive Medicine and Departments of Psychiatry and Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
Peter
P
Vollenweider
Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France; Paris Descartes University, Paris, France.
Marie
M
Zins
Harvard T H Chan School of Public Health, Boston MA, USA.
Ichiro
I
Kawachi
University College London, Department of Epidemiology and Public Health, London, UK.
Andrew
A
Steptoe
Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands.
Johan P
JP
Mackenbach
MRC-PHE Centre for Environment and Health, School of Public Health, Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Paolo
P
Vineis
University College London, Department of Epidemiology and Public Health, London, UK; Clinicum, Faculty of Medicine, University of Helsinki, Finland.
Mika
M
Kivimäki
D000328:Adult; D000428:Alcohol Drinking / Q000401:mortality; D015331:Cohort Studies; D015444:Exercise / Q000502:physiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061213:Mortality, Premature; D009765:Obesity / Q000401:mortality; D012307:Risk Factors; D012907:Smoking / Q000401:mortality; D012923:Social Class