A few studies suggest age limits to the effects of some behavior risk factors. Perhaps beyond age 70 or so, those who are still healthy may be less affected by continuing to smoke or being overweight (Crimmins, 2001; Seeman et al., 1994; Strawbridge et al., 1996). Other studies, however, show continued effects at advanced ages (Reed et al., 1998). Previous behavior, at younger ages, could, in particular cases, be of diminishing relevance. This effect has been demonstrated for smoking: people who quit smoking by their mid-40s show no adverse effects by their late 50s, if they survive to that age, relative to those who never smoked (Østbye et al., 2002; Peto et al., 2000). More generally, however, behavior earlier in life predicts later behavior and may have long-term effects not fully accounted for (Warner and Hayward, 2002).

Racial and ethnic groups differ on these behaviors (Bolen et al., 2000; Schoenborn and Barnes, 2002); see Table 5-1. Relative to whites, American Indians and Alaska Natives exhibit less healthy behaviors, and Asians generally healthier behaviors, except in having less leisure-time physical activity. Blacks and Hispanics also have less leisure-time physical activity than whites, and both these groups are more likely to be obese, though the contrast is less sharp for Hispanics. In addition, Hispanics report slightly more binge drinking than whites, but blacks report sharply less. (Drinking patterns are complex, however, showing cultural patterning across nationality groups that persists across generations [Dawson, 1998].)

These risk behaviors may not be independently chosen but may represent a syndrome of risk affinity or aversion. Counting the number of behavior risk factors—and adding such preventive behaviors as colorectal screening—Hahn et al. (2000) confirm that American Indians and Alaska Natives and blacks have a significantly larger number of behavior risk factors than whites, and Asians a significantly smaller number, even controlling for socioeconomic factors.

Men and women are not distinguished in Table 5-1, but gender differences could be important (Winkleby and Cubbin, 2004). If one looks specifically at men and women aged 65-74, the picture becomes more complicated, particularly for blacks. Higher levels of obesity and inactivity, relative to whites, appear mainly for older black women, but not for older black men. And cigarette smoking does appear relatively more common among older black men relative to whites, though not among younger black men nor among black women of any age (Sundquist et al., 2001; Winkleby and Cubbin, 2004).

REASONS FOR VARIATION

Socioeconomic disadvantage is one reason for differences in behavior risk factors. Less education, for instance, is associated with more smoking



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