Income and mortality: the shape of the association and confounding New Zealand Census-Mortality Study, 1981-1999.

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To determine the shape of the income-mortality association, before and after adjusting for confounding by other socioeconomic variables. Poisson regression analyses were conducted on 11.7 million years of follow-up of 25-59 year old New Zealand census respondents spanning four separate cohort studies (1981-1984, 1986-1989, 1991-1994, and 1996-1999). Mortality among low-income people was approximately two times that among high-income people. Adjustment for potential socioeconomic confounders (marital status, education, car access, and neighbourhood socioeconomic deprivation) halved the strength of the income-mortality association, but did not appreciably change the shape of the association. Further adjustment for labour force status largely removed the income-mortality association. The association of non-transformed income with mortality was non-linear, with a flattening out of the slope at higher incomes. Both the logarithm and rank of income appeared to have a better linear fit with the mortality rate, although the association of mortality with the logarithm of income flattened out notably at low incomes. Much, but not all, of the crude association of income with mortality could be due to confounding. Adjusting income-mortality associations for labour force status (also a proxy for health status) is problematic: on the one hand, it over-adjusts the association as poor health will be on the pathway from income to mortality; on the other hand, it appropriately adjusts for both confounding by labour force status and reverse causation whereby income changes as a result of poor health. Both logarithmic and rank transformations of income have a reasonable linear fit with income.