The 1980s and 1990s were periods of rapidly rising life expectancy, but the mortality declines that yielded these gains did not occur evenly by educational group. On average, we find very little change in life expectancy among less educated black and white non-Hispanics, and very substantial increases in life expectancy among the more educated. These patterns mirror similar widening of education differentials in disability and self-reported health status over the same period.24
The growing gap in life expectancy by education occurred during a period of increasing attention to health disparities and increased public spending designed to improve the health of less advantaged populations.
One important exception to this pattern is that educational mortality disparities narrowed among young black men, a finding consistent with recent evidence that racial mortality gaps narrowed in the 1990s. Nevertheless, a 5 year gap in life expectancy between blacks and whites remains.25
Across sex groups, men made faster gains in mortality than women over this period, narrowing mortality and life expectancy gaps by sex.
Our data span a period of rapidly rising income inequality, providing one potential explanation for widening educational disparities. However, data do not support this explanation because health disparities narrowed across race and gender as inequality increased.26
Our results suggest that differential trends in smoking may explain a significant part of widening gaps in mortality and life expectancy. The diseases contributing most to the growing educational gap in mortality include diseases of the heart, lung and other cancers, and COPD, all of which share tobacco use as a major risk factor. Lung cancer and COPD alone account for one quarter of the increasing gap in life expectancy for women over 45, consistent with their sharp divergence in smoking rates during the 1980s. For men, the divergence in smoking was more moderate, as was the increase in the mortality gap attributable to tobacco-related causes of death.
Public policy designed to reduce health consequences related to smoking may have indirectly contributed to this disparity. In the half century since the harms of smoking became widely known, tobacco control measures have proliferated. Cigarette labels warning of the health hazards of smoking have been required since 1966. Cigarette advertising was banned from television and radio in 1971.27
During the 1980s and 1990s, many states and localities instituted smoking bans in the workplace. By 1993, 70% of indoor workers had smoking bans in work,28
and by 2007, every state had some smoke free air provision.29
In addition, cigarette taxes have increased rapidly in recent years, after falling in real terms in the 1970s. On net, the real price of cigarettes has nearly tripled since the 1960s.30
The proliferation of tobacco control policies brought remarkable reductions in tobacco use. In the four decades following the 1964 Surgeon General's report, per capita annual consumption of cigarettes among adults fell by half. However, declines were greatest among the most educated groups. The growing gap in mortality by education for smoking-related causes supports the longstanding paradox that attention to prevention can widen disparities in health across education and income groups.31
In this case, the advances related to knowledge about risk factor control; we cannot say whether the same is true about medical technologies.32
The focus on tobacco does not imply that other efforts to reduce disparities in health were not successful. Indeed, we confirm recent work highlighting relative gains in life expectancy overall for blacks compared with whites during the 1990s.33
Further, other studies have shown that Medicaid expansions targeting low-income pregnant women and children improved health outcomes among these populations.34
Our study does not argue that these policies were unsuccessful. Rather, it suggests that these efforts were swimming against a strong tide, one which overwhelmed billions of dollars spent annually on additional medical care. On the more positive note, our results suggest that one place to look for real progress is tobacco control efforts for low SES groups because mortality trends mimic trends in smoking that occurred decades earlier. These long-run consequences of health behaviors bolster the argument for early childhood intervention.35
The explanation for differential smoking trends is complex. Basic knowledge does not appear to be the major issue. In 1986, 90% of Americans surveyed across the board reported that smoking causes lung cancer and emphysema, and 80% believed it contributed to heart disease and bronchitis.36
Translating knowledge into action has proven more complex, however. Innovations that target less-advantaged groups might offset this unintended consequence of medical progress. Some caution about this conclusion is needed, however. Without addressing the underlying factors that lead less educated individuals to be less able or willing to invest in better health, measures to reduce smoking may simply lead to a shift from tobacco-related deaths to other causes.37
Beyond the differential change in smoking, there is the national trend towards increased obesity. As with smoking, obesity is more common among the less educated than among the better educated. Further, recent research suggests that obesity might contribute to nearly as many deaths as tobacco.38
Although the population health consequences of obesity remain controversial, the obesity trends in recent years and into the future could further widen socioeconomic gaps in health.
In summary, during a period of increased focus on disparities in health, virtually all gains in life expectancy occurred among highly educated groups. Causes of death related to differential trends in cigarette smoking by education have contributed substantially to rising mortality differentials. Larger and better targeted efforts to push successful health interventions into less educated groups may be needed to achieve the goal of reducing disparities in health by socioeconomic group.