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Patrick M. Krueger, PhD and Virginia W. Chang, MD, PhD

Patrick M. Krueger is with the Division of Management, Policy, and Community Health, University of Texas School of Public Health, Houston, and the Population Research Center, University of Texas, Austin. Virginia W. Chang is with the Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, and the Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.

Correspondence: Requests for reprints should be sent to Patrick M. Krueger, PhD, University of Texas School of Public Health, 1200 Herman Pressler, RAS E-907, Houston, TX 77030 (e-mail: patrick.m.krueger{at}uth.tmc.edu).

Objectives. Individuals may cope with perceived stress through unhealthy but often pleasurable behaviors. We examined whether smoking, alcohol use, and physical inactivity moderate the relationship between perceived stress and the risk of death in the US population as a whole and across socioeconomic strata.

Methods. Data were derived from the 1990 National Health Interview Survey’s Health Promotion and Disease Prevention Supplement, which involved a representative sample of the adult US population (n=40335) and was linked to prospective National Death Index mortality data through 1997. Gompertz hazard models were used to estimate the risk of death.

Results. High baseline levels of former smoking and physical inactivity increased the impact of stress on mortality in the general population as well as among those of low socioeconomic status (SES), but not middle or high SES.

Conclusions. The combination of high stress levels and high levels of former smoking or physical inactivity is especially harmful among low-SES individuals. Stress, unhealthy behaviors, and low SES independently increase risk of death, and they combine to create a truly disadvantaged segment of the population.