This by Sandro Galea in JAMA Health Forum has a lot of good information, but it isn't really the whole story. As we all know, there are large disparities in health and longevity associated with income -- the richest Americans live on average ten years longer than the poorest. Galea cites a study by Puka et al that attributes these disparities to behaviors such as smoking, excessive drinking, and lack of physical activity, though to be precise the Puka studied correlated these behaviors with level of formal education, not income.
Galeo is at pains to argue that just targeting risk behaviors misses the real point because there must be something causal about socioeconomic status and behavior. Well yes, but that's very complicated. It's also not the whole story. The famous Whitehall II study in Britain found that among British civil servants, occupational status -- managerial, professional, skilled labor and unskilled -- was strongly associated with longevity. And while smoking, poor diet and inactivity contributed, disparities remained even while controlling for these risk behaviors. Psychosocial stress and lack of agency seem to contribute.
Lower income people are also more exposed to air pollution, because they are more likely to live near highways and other pollution sources; to occupational hazards; to violence and other external risks. They often have poorer diet because they live in so-called "food deserts," places where there are no grocery stores selling fresh produce and in any case, a poor diet is cheaper. They can't exercise because they can't afford a gym membership and the parks and streets aren't safe. And so on. Eliminating disparities is not just about encouraging people to quit smoking. It's about fundamental social conditions.
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