In this prospective study of older U.S. adults, we found that men and women residing in the most deprived census tracts had an increased risk of dying (approximate 15% and 10% occurred for all-cause and cancer deaths, respectively) compared to those in the least deprived areas, with the greatest risks being for CVD mortality (men, 33%; women, 18%). This excess risk was observed even after accounting for a gamut of known risk factors, including age, education, smoking, physical activity and dietary intake. Our results emphasize the importance of neighborhood SES and related contextual factors for decreasing the risk of mortality from the two leading causes of death: cardiovascular disease and cancer.
Few previous studies have examined sex-specific differences in the pathways that produce socioeconomic mortality gradients. Our relative risks of CVD mortality for women residing in high deprivation areas are consistent with those reported by LeClure and colleagues for a similar age group when examining individual neighborhood characteristics, i.e., percent female headship 
. Further, our finding of a sex difference between deprivation and CVD mortality are in accord with studies, which found that the socioeconomic-mortality association is weaker in women than men for person-level indicators of SES 
Our results are not in accord with those reported by Bosma and colleagues who examined individual neighborhood SES characteristics in a specific geographical area of the Netherlands for a wider age range, 15–74 years 
. The lower risks observed for total mortality in our study may in part be explained by differences in the study populations, with NIH-AARP Study having less variability in SES and comprised of older adults (50–71 yrs). Stronger effects of deprivation on mortality have been reported for younger age groups 
. Another important difference is that we accounted for a broader array of individual risk factors, such as smoking, physical activity, and dietary intake, which attenuated the relative risks.
The present study extends what has been done in previous studies by using a composite measure of neighborhood socioeconomic deprivation comprised of ten individual census variables, evaluating effects separately for men and women, examining all-cause as well as cancer and CVD-related deaths, accounting for an extensive list of individual risk factors, and is not restricted to a specific geographic area 
. Our results indicate an independent relation between area-level deprivation and mortality lending further support for future research and interventions to consider both person- and area-level factors of deprivation.
Potential mechanisms by which neighborhood deprivation may influence mortality include physical environment/environmental exposures and social norms. In particular, areas with higher deprivation may have issues such as limited availability of or access to healthy foods and health care, higher environmental pollution, and lack of social networks that might also impact mortality risk independently of the characteristics of the people living in those areas 
. We were unable to examine the potential influence of physical environment in the present study. There was some evidence that social norms may have played a role in the increased risk of mortality since the risk estimates for deprivation were further attenuated after adjusting for behavioral risk factors that may reflect the social norms of more deprived areas (e.g., smoking, high BMI) 
Among the inherent strengths of the present study is the prospective design in which individual- and area-level factors were measured prior to mortality. Extensive data collection of information on lifestyle and medical history allowed us to control for possible confounding on a broad array of characteristics and lifestyle factors. In addition, we employed an innovative analytic method, the extended Cox model with a robust variance estimator, to simultaneously examine associations of person-level and area-level risk factors with mortality, which is unique in research evaluating the effects of neighborhood deprivation on death. Further, the large size of the NIH-AARP Study allowed us to stratify the study population by gender and examine interactions while maintaining study power.
A limitation of our study is that the cohort was predominantly older, upper-to-middle class Caucasians; therefore, results may not apply to other populations. Yet even within the NIH-AARP study population that may have a limited range of neighborhood deprivation scores, we were still able to observe an effect of deprivation on mortality. It is possible that this effect might actually be larger for a population with a wider range of socioeconomic status. It is also possible that results for neighborhood deprivation reflect incomplete adjustment for person-level factors, including household income and occupation. Given that this is an older cohort with many retirees, individuals may have relocated after retirement and therefore the census track at study baseline may not reflect that of younger ages. Although information on long-term residency was not ascertained in the present study, the NIH-AARP did collect a wide range of characteristics and lifestyle factors, including dietary intake, that are typically not available in other study populations. Because we investigated multiple endpoints, it is possible that significant results may be due to chance. Future studies are needed to replicate these findings.
In conclusion, our data provide support for an independent relation between neighborhood socioeconomic deprivation and mortality in both men and women, even after accounting for a large number of known risk factors for mortality. Our findings require confirmation in other U.S. populations, including younger age groups and populations with a wider range of SES. If confirmed, further studies are needed to identify important pathways (e.g., access to and quality of health services, social networks, air quality, etc.) that may underlie these results. Identification of these pathways could have important public health and policy implications.