Explaining the Widening Divides in US Midlife Mortality: Is There a Smoking Gun?
nber.org54 points by bikenaga 15 hours ago
54 points by bikenaga 15 hours ago
From a layman's perspective, it seems like it's mostly an expected outcome of college degrees becoming a class signifier. In 1990, only a fifth of American adults had bachelor's degrees, with those who held them making 70% more than high school graduates. A sizeable gap, sure, but those non-college graduates have minimum wage retail workers and general laborers, and union steel and auto workers in the same educational bucket.
By 2020, it had risen to well over a third of Americans who had bachelor's, and 105% more income for those with them. One might expect a dilution in a degree's value, but I think it's just a matter of minimum wage workers still being high school graduates, whereas virtually all professional workers (including the increasingly few manufacturing workers) needing a bachelor's to get past the first stage of HR.
[1] https://educationdata.org/education-attainment-statistics
[2] https://en.wikipedia.org/wiki/Educational_attainment_in_the_...
10% increase is a lot lower than I anticipated what with all the talk about a B.S. being the barrier for entry these days.
Apparently nearly half of college students drop out. [1] That gives us most people going to college, but a significant portion not graduating.
20% to 33% is not a 10% increase, if that’s what you’re referring to. That’s a 65% increase.
Even still, over more than two decades, only a ten percentage point increase is still somewhat mind-blowing.
As someone who grew up upper middle class in a wealthier suburban area, I lived in a bubble where the vast majority of people I went to high school with went off to college and got bachelors degrees. To me, it seemed that that was the norm for most Americans, but that's far from reality.
65% increase seems big but this also means only 13% more adult americans are degree holders which seems remarkably paltry to me after almost 40 years of "thou shall go to college" being preached to highschoolers.
Only about half of Americans who go to college finish their degree. The saddest part of the college debt crisis are the kids with debt and no degree to pay it off.
College got very expensive. If it hadn’t I’m sure we’d see higher numbers.
I think that depends on if you go out of state or in state. My alma mater has frozen in state tuition for at least 10 years now, maybe longer. Plenty of flagship in state schools are only around 12k-15k a year. In a world where you can now crack 15 an hour unskilled now while living with the parents over the summer you can probably cover a lot of that almost like it was in ye olden times.
Seems like things have been relatively flat for the last decade, but costs are roughly double what they were 30 years ago.
https://www.npr.org/2025/11/20/nx-s1-5600854/college-costs-h...
I don't follow? If the population of college educated adults is growing, it's by definition becoming less selective and would be expected to show less skew. College educated people used to be a "special" demographic, now they're much closer to the rest of society. But the data shows the opposite effect, with the lifespan benefit of a degree more than doubling.
I think there is something to be said about provenance of the degree. For example there's been quite a lot of expansion in number of colleges or even community colleges expanding their systems while actual prestigious colleges themselves have only expanded so much.
Here are the stats for Harvard enrollment of undergrads (1,3), along with US population (2,4) and percent Harvard student (not sure where I get number of people in the workforce with harvard degrees data but maybe this is a decent proxy):
Year - ugrads - US population - % of US pop at harvard
1990 - 22,851 - 248,709,873 - 0.0092%
2000 - 24,279 - 281,421,906 - 0.0086%
2010 - 27,594 - 308,745,538 - 0.0089%
2025 - 24,519 - 343,000,000 - 0.0071%
1. https://nces.ed.gov/programs/digest/d13/tables/dt13_312.20.a...
2. https://www.census.gov/data/tables/time-series/dec/popchange...
Let me just write this down… Just for illustration, assume average lifespan of poor person is 60 and average lifespan of rich person is 80, 30% of the population is from the rich person group and rest from the poor person group, and these two facts hold for current time and the 90s.
Let’s say currently, every rich person goes to college, so college to non-college lifespan is 80:60.
While in the 90s, let’s say 20% goes to college and every college going person is rich. Then the lifespan of college going person would still be 80 and non-college going person would be more than 60.
So, another way of looking at it is that the non-college going population is getting to be the special demographic whose statistics are getting skewed, though I’m not sure that’s the correct way of looking at it.
It might be a skewed distribution where life expectancy drops off rapidly below the median but isn’t that different at the top. So it’s not a big difference when it’s the bottom 90% and the top 10%, but it is when it’s the bottom 60% versus the top 40%.
Well, sure, but generally when your hypothesis demands a highly non-linear distribution function to make sense, it's just wrong. That might be true; the math could be made to work. But if it were, that is the result the study would be pushing and not the bland thing about smoking.
It's a smell test thing, basically.
As I understand the data in this article, midlife mortality rates for those who hold college degrees has declined from 1992 to 2019, whereas the rate has remained largely stable for non-college degree holders.
I wonder if this trend is due, in part, to college degree holders becoming disproportionately female over time, and women having lower midlife mortality rates? https://www.aei.org/wp-content/uploads/2018/05/degrees-1.png
Given that Americans with and without college degrees are split pretty much 50/50, then we’d expect there to be an equal increase in non-college degrees holder mortality rates if this was caused by changing who got degrees.
I suppose it’s possible that the gender ratio change is the cause of half of the mortality decrease, and the other half is a broad decrease in mortality rates. That would cause it to cancel out in non-college degrees holder mortality holders and double in college degree holders.
It's exactly these kind of issues with statistics that cause us all kinds of problems. I'm glad you pointed this one out.
It reminds me of a YT video I was watching with similar issues about cancer mortality rates. We've been doing all these treatments, and cancer survival rates have been going up. So everybody cheers about how good the treatments are. But when you control for the fact that earlier detection puts more people into the 'cancer' category earlier, causing 'cancer' people to live statistically longer from diagnosis, then the benefits of the treatments mostly go away (for many but not all types of cancer).
And these kinds of misleading issues are all throughout statistics. See Simpson's paradox, etc.
This seems like an extremely broad brush. There are cancers that were literally untreatable and guaranteed death within years, that with treatment now can see patients living 5+ years. Lung cancer specifically, but others as well.
Not just more female, but also a broader proportion of the population in total. You'd need to control for these effects to draw any conclusions at all.
> Less well-understood is why “place effects” matter so much for smoking (and mortality) for those without a college degree.
Let me take a crack at it: people with college degrees tend to be found in populous places and spaces where smoking is prohibited. Plus, social pressure; lighting up a cigarette in certain company is almost like hurling a racist insult.
Just to get through college with a cigarette habit would have been a pain in the ass. You can't be darting outside N times during lectures or exams to have a smoke. If you can even do that; a lot of colleges nowadays have even outdoor smoking bans, no? That's sort of a place effect: college graduates spend a bunch of time in certain places where smoking would have been inconvenient to the point of making some people quit.
Your argument as it stands would explain why people with college degrees smoke a lot less than people without them. But that's not what the "place effects" is in the article. "Place effects" is the fact that, if we just look at non-college-graduates, the ones who live in rural areas smoke more and have lower life expectancy than the ones who live in urban areas.
The latter effect, I think, can be explained by an argument that's similar to yours: even for non-college graduates, it's a lot more inconvenient to be a smoker in urban areas than in rural areas. You're much more likely to find smoking banned inside the places you go, and to face social disapproval if you try to smoke outdoors in public spaces.
What eras? I went to college in a non-populous place circa ~2001-2005 and in our state smoking bans were just starting to roll out then. Smoking was an everyone thing, and it was normal to go to smokey places on a regular basis even if you didn't smoke. That was nuts and bad of course, but it was normalized.
Similar but a little later and when I started it seemed like everyone smoked, but by the time I graduated it was basically no one.
I went to a school in downtown Toronto and we had 10 minute breaks every hour in lectures. I also knew a ton of classmates who smoked.
Starting to wonder if the two are correlated.
It's access to good health in midlife. I know people who have tests, good healthcare, I can afford it, both with time off and with my healthcare coverage itself and the cost of other optional tests.
I'm one of the millions of Americans in the other group. If I get a treatable, life threatening disorder, I die.
We don't get a lot of press. During the first decade of the ACA we didn't exist for anyone reporting on the US healthcare system.
But our visibility has improved and some days we're almost noticed for moments at a time.
We need to fix this problem and provide great health care to all. Half the country seems to think it's some kind of impossible communism country destroying things to give everyone good health care like every other developed country. How can it be that Republicans keep convincing their voters if this? Raise taxes a little on the wealthy, go to single payer
It's a hard sell because most self employed and middle income people actually had reasonable insurance and then the ACA completely screwed them. Sure single payer and universal coverage would be great but how could you trust Democrats to do it when the last healthcare bill was basically one of the worst things to ever happen to the country. ~95% of people that don't work for insurance companies would be better off under the previous system. Just expand Medicaid to include people unable to get insurance due to pre-existing conditions and eliminate coverage maximums, or just say anything over 2 million in a year goes through Medicaid.
The ACA is just a huge transfer of tax payer money to insurance companies.
"Abstract. The education-mortality gradient has increased sharply in the last three decades, with the life-expectancy gap between people with and without a college degree widening from 2.6 years in 1992 to 6.3 years in 2019 (Case and Deaton 2023). During the same period, mortality inequality across counties rose 30 percent, accompanied by an increasing rural health penalty. Using county- and state-level data from the 1992–2019 period, we demonstrate that these three trends arose due to a fundamental shift in the geographic patterns of mortality among college and non-college populations. First, we find a sharp decline in both mortality rates and geographic inequality for college graduates. Second, the reverse was true for people without a college degree; spatial inequality became amplified. Third, we find that rates of smoking play a key role in explaining all three empirical puzzles, with secondary roles attributed to income, other health behaviors, and state policies. Less well-understood is why 'place effects' matter so much for smoking (and mortality) for those without a college degree."
Seems dubious to me that smoking explains any of these things. I would guess just a cultural cofounder.
Obesity and fentanyl would be my guess.
Smoking is a major health risk, so it makes sense to me that it's a major factor. Not sure why you'd want to remove it as a confounder.
I think parent comment was pointing to lack of establishing a causation link. The finding in their abstract is extrapolated by statistical inference. For example smokers tend to drink more etc. The paper does take such factors into account. Personally I wouldn't jump to such a strong conclusion from statistical inference because it closes the door on other factors that might be even stronger when combined together. The paper reflects motivated reasoning more than a discovery outcome. That said, smoking is of course a major health risk, I am just pointing at the research approach.
Smoking is a major health issue, but it's barely a driver of midlife mortality. Smoking tends to kill you later.
When my city banned public smoking, there was an immediate and statistically significant decrease in heart attacks and strokes.
Smoking is bad for you, but it's unlikely to kill you in midlife.
In the paper they claim it matters for midlife mortality too:
> People who start smoking at age 18 begin to exhibit higher mortality several decades later, with particularly large effects beginning at ages 45–64 (Lawton et al. 2025). A health-capital model allows the mortality rates of older persons to be determined not only by their current smoking behavior but also by smoking in earlier years. In the United States, smoking rates started falling for college graduates earlier than they did for the non-college population.
...
> [...] with rapidly improving treatments and screening for lung cancer (Howladeret al. 2020), the major impact of smoking over the longer-term—particularly for people aged 55–64 arises from other more-common tobacco-related diseases such as chronic obstructive pulmonary disease (COPD); cardiovascular diseases such as strokes, aneurysms, and heart attacks; diabetes; and other types of cancers (Carter et al. 2015). Perhaps more surprising is that past county-level smoking rates are highly predictive of deaths of despair. This finding, however, is consistent with an emerging literature in biology that points to a causal influence of smoking on drug addiction [...]
It is associated with other adverse behaviors like a sedentary lifestyle. Smokers aren't generally athletically motivated.
Actually, later in their paper they say: "Although we have argued for a causal role for smoking in generating these patterns, the growing mortality gaps still seem too large and the causes of death too varied to blame the patterns on the adverse health effects of tobacco use alone. As noted above, smoking is likely to play a role in amplifying the impact of other factors adversely affecting midlife mortality, such as the marketing efforts by opioid manufacturers targeted to areas with high rates of smoking-related illness, coupled with epigenetic changes making smokers more susceptible to opioid use disorders. Still, the strength of our findings that smoking is predictive of spatial trends in midlife mortality points towards different mechanisms needed to explain the troubling trends that have unfolded since 1990."
> manufacturers targeted to areas with high rates of smoking-related illness
Oof
> epigenetic changes making smokers more susceptible to opioid use disorders
This one seems… a bit mystic to me. I would have been much quicker to suggest that a psychological propensity to start smoking mirrors a propensity to start using other drugs vs. arguing for emergent effects of cellular behavior.
Yeah it seems silly.
Why is college the primary group factor…? Is there some sort of health effect of sitting college classrooms for 5 years? Seems unlikely.
College education is highly associated and predicted by income/access to wealth.
Wealth inequality seems like a more likely explanation. Not seeing how they controlled for that across college vs non-college groups.
So it's basically saying that smoking is a proximal cause of mortality, and locale is a distal cause of smoking, intensified by not having a college degree?
K-shaped growth, dual economy, permanent underclass what ever you want to call it, shapes all aspects of life.
Call it what it actually is: societal abuse from wealthy oligarchs with their masks removed. One man bought up all the RAM on planet Earth, and everyone's like "lol I guess computers are just expensive now".
For Second-Handers the value of DRAM collapses past 256K anyway. I'd rather the people who can actually use it get societies resources than bums who use it to play games and crap out dumb scribbles or "vfx"
Second-Handers love to denigrate the work of Elon Musk and Sam Altman, but these men are solving fundamental problems, you can get your DRAM on the second-hand market after Sam uses it to create AGI. A reasonable man would be very grateful for the existence of these oligarchs. I assume you are just posting unconsciously not unreasonably.
If you have a college degree, you might be able to work from home and not take your life in your hands twice a day on a freeway of death. If you don't have a college degree, you probably have to commute. If you live in a rural area you probably have to commute long distances, with low lighting on potentially icy and twisty single lane roads with oncoming traffic. In all the discussions of RTO vs WFH you almost never see safety mentioned, but it's an incredible upside to not having to drive to and from work every day.
There is also the added stress of commuting, which its fair to assume has negative impacts on heart, cognitive, etc. health.
Stress, risk, and stress compounding risk. So many people speed recklessly after having been stuck in traffic.
I would, however, not strongly link WFH to college and RTO to non-college. Many companies (as well as governments) have implemented RTO. The key outlier for WFH seems to be contracts and/or good negotiation skills.
Agreed (without regard to applicability of this article) - I was hit twice (i.e. other cars running into mine, their fault) within a calendar year after 5 day RTO went into effect in mid 2024 at work here (the valley).
Not that America's car culture isn't a dangerous problem, but I'm pretty sure highway deaths don't explain this...
What percent of work from homers actually avoid the highway of death? Sure there are some living an urban car free lifestyle working from home, but plenty chose the opposite for their remote work, choosing space and inconvenience from job centers which in America inevitably means car centric exurban or rural living. I'd wager you are more at risk driving 5 miles for groceries on one of those single lane per direction 50mph rural roads than you are commuting in rush hour traffic at 16mph.
I'd love to see some actual data, but I'd bet that a large majority of pandemic WFH moves were to midrange CoL suburb sorts of areas that have reasonable job prospects within reach, so should push come to shove and they need to find local butt-in-seat employment they can. Major hospitals, airports, etc being reasonable to access is a big draw too.
That's what I did. Groceries are a 10m drive away on a bad day. I've lived the rural life and it's not glamorous so I have no desire to return.
Of course some did make the move out to places like you're mentioning, but my suspicion is that this group is actually not that large and the big splash they made in media (traditional and social) made their numbers seem greater than they are.
I went from 5 days a week or 2 hours per day behind the wheel to essentially nothing, maybe I drove once a week, maybe
Your wager is nonsense by the way.
I'm not so sure it is nonsense. Those rural 50mph roads are generally considered the most dangerous road type and many states prioritize turning them into actual divided roads due to prevalence of fatal accidents. Admittedly the rush hour traffic experience depends a lot on where you live; in the midwest you probably only see congestion on the exit itself and are otherwise going the full 60mph on even urban freeways, whereas in places like LA or NYC you aren't breaking a 16mph average no matter what road you are on during rush hour. Not a lot of ways to die going 16mph...
I don't buy it. Road fatalities are probably the single easiest hypothesis to isolate. You can't put a label on a cancer or heart attack death, but you sure can for trauma deaths.
Boomers need to be kept unaware of how everything is changing for the worse or they might vote differently
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