Trends in Socioeconomic Inequalities in Adult Health Behaviors among U.S. States, 1990-2004

Objective: The purpose of this study was to measure state trends in educational inequalities in smoking, binge alcohol use, physical inactivity, obesity, and seatbelt use. Methods: The authors calculated the Relative Concentration Index of educational inequality for five health behaviors on adults from all 50 states and the District of Columbia using data from 1990 to 2004 in the Behavioral Risk Factor Surveillance System (n=2,118,562). Linear regression was used to measure changes and trends in the Relative Concentration Index of health inequality across education groups in each state. Results: Except for binge alcohol use, poorer health behaviors were concentrated among the less educated. The largest educational inequalities were for physical inactivity. From 1990 to 2004, significant increases in relative educational inequalities occurred in 40 states for smoking and 31 states for physical inactivity. For binge alcohol use, 27 states showed significant declining inequality trends, but educational inequalities reversed direction and binge alcohol use is now more prevalent among the less educated in 19 states. Significant decreases in educational inequalities occurred in 36 states for obesity and 24 states for seat belt use. Changes in educational inequalities across the different health behaviors were not associated, except for a modest correlation between changes in inequality in smoking and binge alcohol use (r=0.40; p=0.004). Similarly, there was little association between changes in the population prevalence of health behaviors and changes in educational inequality in health behaviors, with substantial heterogeneity among states. Conclusions: State trends in relative educational inequality among health behaviors were mixed, increasing for smoking and physical inactivity and decreasing for obesity and seat belt use. The factors influencing relative inequality trends may differ from those affecting overall prevalence trends.