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Tobacco smoking is the major preventable cause of cancer. Despite the longstanding decline in smoking prevalence, lung cancer remains one of the most frequently diagnosed cancers in both sexes. We aimed to estimate the current cancer burden attributable to smoking in Europe. Smoking-related cancer incidence by country, cancer type, sex and age in Europe was estimated from GLOBOCAN 2018. We applied a modified version of the indirect method to estimate the population attributable fraction (PAF) for lung cancer and applied Levin's formula to estimate the PAF for other smoking-related cancer sites. In Europe in 2018, 572,000 and 186,000 cancer cases were attributable to tobacco smoking in males and females respectively, accounting for 28% (males) and 10% (females) of all cancer cases. By region, the largest and the lowest PAF due to smoking in males occurred in Eastern Europe (35% of all cancer cases) and Northern Europe (21%), respectively. Among women, this pattern was reversed (16% in Northern Europe and 6% in Eastern Europe). Lung cancer accounted for more than half of the total cancer burden attributable to smoking (382,000). Other major contributors to the total PAF were lip, oral cavity and pharynx, bladder and laryngeal cancers in men (27% out of total PAF) and colorectal, pancreatic, oral cavity and pharyngeal cancers (21%) in women. Tobacco smoking was responsible for one in five cancer cases in Europe in 2018. The introduction and robust implementation of tobacco control programmes are critical to reduce this cancer burden in the future. • Despite health policy efforts smoking caused 1 in 5 cancer cases in Europe in 2018. • Regional variation in the range of 10–30% of cancer cases attributable to smoking. • The results suggest urgent need for tobacco control policies in the EU legislation. [ABSTRACT FROM AUTHOR]

Background: Ischaemic heart disease (IHD) is one of the leading causes of death worldwide with a higher risk of dying among people with a lower socioeconomic status. We investigated the potential for reducing educational differences in IHD mortality in 21 European populations based on two counterfactual scenarios--the upward levelling scenario and the more realistic best practice country scenario. Methods: We used a method based on the population attributable fraction to estimate the impact of a modified educational distribution of smoking, overweight/obesity, and physical inactivity on educational inequalities in IHD mortality among people aged 30-79. Risk factor prevalence was collected around the year 2000 and mortality data covered the early 2000s. Results: The potential reduction of educational inequalities in IHD mortality differed by country, sex, risk factor and scenario. Smoking was the most important risk factor among men in Nordic and eastern European populations, whereas overweight and obesity was the most important risk factor among women in the South of Europe. The effect of physical inactivity on the reduction of inequalities in IHD mortality was smaller compared with smoking and overweight/obesity. Although the reduction in inequalities in IHD mortality may seem modest, substantial reduction in IHD mortality among the least educated can be achieved under the scenarios investigated. Conclusion: Population wide strategies to reduce the prevalence of risk factors such as smoking, and overweight/obesity targeted at the lower socioeconomic groups are likely to substantially contribute to the reduction of IHD mortality and inequalities in IHD mortality in Europe. [ABSTRACT FROM AUTHOR]

Background: Obesity contributes considerably to the problem of health inequalities in many countries, but quantitative estimates of this contribution and to what extent it is modifiable are scarce. We identify the potential for reducing educational inequalities in all-cause and obesity-related mortality in 21 European populations, by modifying educational differences in obesity and overweight. Methods: Prevalence data and mortality data come from 21 European populations. Mortality rate ratios come from literature reviews. We use the population attributable fraction (PAF) to estimate the impact of scenario-based changes in the social distribution of obesity on educational inequalities in mortality. Results: An elimination of differences in obesity between educational groups would decrease relative inequality in all-cause mortality between those with high and low education by up to 12% for men and 42% for women. About half of the relative inequality in mortality could be reduced for some causes of death in several countries, often in southern Europe. Absolute inequalities in all-cause mortality would be reduced by up to 69 (men) and 67 (women) deaths per 100000 person-years. Conclusion: The potential reduction of health inequality by an elimination of social inequalities in obesity might be substantial. The reductions differ by country, cause of death and gender, suggesting that the priority given to obesity as an entry-point for tackling health inequalities should differ between countries and gender. [ABSTRACT FROM AUTHOR]

Background Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. Methods We collected and harmonised data on mortality by educational level among men and women aged 30–74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. Results Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. Conclusions Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes. [ABSTRACT FROM AUTHOR]

Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a “fundamental cause” which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities. We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30–79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable. Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education–mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large. In conclusion, our results provide some further support for the theory of “fundamental causes”. However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks. [ABSTRACT FROM AUTHOR]

Introduction: Smoking is an important determinant of socioeconomic inequalities in mortality in many countries. As the smoking epidemic progresses, updates on the development of mortality inequalities attributable to smoking are needed. We provide estimates of relative and absolute educational inequalities in mortality from lung cancer, aerodigestive cancers, and chronic obstructive pulmonary disease (COPD)/asthma in Europe and assess the contribution of these smoking-related diseases to inequalities in all-cause mortality. Methods: We use data from 18 European populations covering the time period 1998–2007. We present age-adjusted mortality rates, relative indices of inequality, and slope indices of inequality. We also calculate the contribution of inequalities in smoking-related mortality to inequalities in overall mortality. Results: Among men, relative inequalities in mortality from the 3 smoking-related causes of death combined are largest in the Czech Republic and Hungary and smallest in Spain, Sweden, and Denmark. Among women, these inequalities are largest in Scotland and Norway and smallest in Italy and Spain. They are often larger among men and tend to be larger for COPD/asthma than for lung and aerodigestive cancers. Relative inequalities in mortality from these conditions are often larger in younger age groups, particularly among women, suggesting a possible further widening of inequalities in mortality in the coming decades. The combined contribution of these diseases to inequality in all-cause mortality varies between 13% and 32% among men and between −5% and 30% among women. Conclusion: Our results underline the continuing need for tobacco control policies, which take into account socioeconomic position. [ABSTRACT FROM PUBLISHER]

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic inequalities in mortality are one of the greatest challenges for health policy in all European countries, but the potential for reducing these inequalities is unclear. We therefore quantified the impact of equalizing the distribution of six risk factors for mortality: smoking, overweight, lack of physical exercise, lack of social participation, low income, and economic inactivity. Methods: We collected and harmonized data on mortality and risk factors by educational level for 21 European populations in the early 2000s. The impact of the risk factors on mortality in each educational group was determined using Population Attributable Fractions. We estimated the impact on inequalities in mortality of two scenarios: a theoretical upward levelling scenario in which inequalities in the risk factor were completely eliminated, and a more realistic best practice scenario, in which inequalities in the risk factor were reduced to those seen in the country with the smallest inequalities for that risk factor. Findings: In general, upward levelling of inequalities in smoking, low income and economic inactivity hold the greatest potential for reducing inequalities in mortality. While the importance of low income is similar across Europe, smoking is more important in the North and East, and overweight in the South. On the basis of best practice scenarios the potential for reducing inequalities in mortality is often smaller, but still substantial in many countries for smoking and physical inactivity. Interpretation: Theoretically, there is a great potential for reducing inequalities in mortality in most European countries, for example by equity-oriented tobacco control policies, income redistribution and employment policies. Although it is necessary to achieve substantial degrees of upward levelling to make a notable difference for inequalities in mortality, the existence of best practice countries with more favourable distributions for some of these risk factors suggests that this is feasible. [ABSTRACT FROM AUTHOR]

Objectives: Our objective was to assess morbidity trends in Europe and to classify European countries based on population ageing theories: the compression, expansion and dynamic equilibrium of morbidity., Methods: The proportions of healthy life years were calculated for 31 European countries for the period 2005-2019 based on life expectancy values and healthy life years at age 65 years adopted from the Eurostat database. European countries were classified according to morbidity patterns applying the standard deviation distance from the average of relative change method between the selected years., Results: A large degree of variation in terms of life expectancy and healthy life years at age 65 years was determined between 2005 and 2019. While the life expectancy differences between men and women were consistent across all the European countries, the gender gap concerning healthy life years was more diverse. Approximately one-third of the countries fell into the expansion, compression and dynamic equilibrium categories, respectively., Conclusion: Significant variations were identified in healthy life year trends across European countries, which underscores the need for preventive strategies., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Straka, Šídlo and Kulhánová.)

Background: Educational inequalities in health and mortality in European countries have often been studied in the context of welfare regimes or political systems. We argue that the healthcare system is the national level feature most directly linkable to mortality amenable to healthcare. In this article, we ask to what extent the strength of educational differences in mortality amenable to healthcare vary among European countries and between European healthcare system types., Methods: This study uses data on mortality amenable to healthcare for 21 European populations, covering ages 35-79 and spanning from 1998 to 2006. ISCED education categories are used to calculate relative (RII) and absolute inequalities (SII) between the highest and lowest educated. The healthcare system typology is based on the latest available classification. Meta-analysis and ANOVA tests are used to see if and how they can explain between-country differences in inequalities and whether any healthcare system types have higher inequalities., Results: All countries and healthcare system types exhibited relative and absolute educational inequalities in mortality amenable to healthcare. The low-supply and low performance mixed healthcare system type had the highest inequality point estimate for the male (RII = 3.57; SII = 414) and female (RII = 3.18; SII = 209) population, while the regulation-oriented public healthcare systems had the overall lowest (male RII = 1.78; male SII = 123; female RII = 1.86; female SII = 78.5). Due to data limitations, results were not robust enough to make substantial claims about typology differences., Conclusions: This article aims at discussing possible mechanisms connecting healthcare systems, social position, and health. Results indicate that factors located within the healthcare system are relevant for health inequalities, as inequalities in mortality amenable to medical care are present in all healthcare systems. Future research should aim at examining the role of specific characteristics of healthcare systems in more detail., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group., Design: Register based study., Data Source: Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively)., Setting: All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania., Results: Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations., Conclusions: Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Socioeconomic inequalities in alcohol-related mortality have been documented in several European countries, but it is unknown whether the magnitude of these inequalities differs between countries and whether these inequalities increase or decrease over time., Methods and Findings: We collected and harmonized data on mortality from four alcohol-related causes (alcoholic psychosis, dependence, and abuse; alcoholic cardiomyopathy; alcoholic liver cirrhosis; and accidental poisoning by alcohol) by age, sex, education level, and occupational class in 20 European populations from 17 different countries, both for a recent period and for previous points in time, using data from mortality registers. Mortality was age-standardized using the European Standard Population, and measures for both relative and absolute inequality between low and high socioeconomic groups (as measured by educational level and occupational class) were calculated. Rates of alcohol-related mortality are higher in lower educational and occupational groups in all countries. Both relative and absolute inequalities are largest in Eastern Europe, and Finland and Denmark also have very large absolute inequalities in alcohol-related mortality. For example, for educational inequality among Finnish men, the relative index of inequality is 3.6 (95% CI 3.3-4.0) and the slope index of inequality is 112.5 (95% CI 106.2-118.8) deaths per 100,000 person-years. Over time, the relative inequality in alcohol-related mortality has increased in many countries, but the main change is a strong rise of absolute inequality in several countries in Eastern Europe (Hungary, Lithuania, Estonia) and Northern Europe (Finland, Denmark) because of a rapid rise in alcohol-related mortality in lower socioeconomic groups. In some of these countries, alcohol-related causes now account for 10% or more of the socioeconomic inequality in total mortality. Because our study relies on routinely collected underlying causes of death, it is likely that our results underestimate the true extent of the problem., Conclusions: Alcohol-related conditions play an important role in generating inequalities in total mortality in many European countries. Countering increases in alcohol-related mortality in lower socioeconomic groups is essential for reducing inequalities in mortality. Studies of why such increases have not occurred in countries like France, Switzerland, Spain, and Italy can help in developing evidence-based policies in other European countries.

Objectives: Using new facilities for linking large databases, we aimed to evaluate for the first time the magnitude of relative and absolute educational inequalities in mortality by sex and cause of death in the Netherlands., Methods: We analyzed data from Dutch Labour Force Surveys (1998-2002) with mortality follow-up 1998-2007 among people aged 30-79 years. We calculated hazard ratios using Cox proportional hazards model, age-standardized mortality rates and partial life expectancy by education. We compared results for the Netherlands with those for other European countries., Results: The relative risk of dying was about two times higher among primary educated men and women as compared to their tertiary educated counterparts, leading to a gap in partial life expectancy of 3.4 years (men) and 2.4 years (women). Inequalities in mortality are similar to those in other countries in North-Western Europe, but inequalities in lung cancer mortality are substantially larger in the Netherlands, particularly among men., Conclusions: The Netherlands has large inequalities in mortality, especially for smoking-related causes of death. These large inequalities require the urgent attention of policy makers.

This study analyses occupational class inequalities in all-cause mortality and four specific causes of death among men, in Europe in the early 2000s, and is the most extensive comparative analysis of occupational class inequalities in mortality in Europe so far. Longitudinal data, obtained from population censuses and mortality registries in 14 European populations, from around the period 2000-2005, were used. Analyses concerned men aged 30-59 years and included all-cause mortality and mortality from all cancers, all cardiovascular diseases (CVD), all external, and all other causes. Occupational class was analysed according to five categories: upper and lower non-manual workers, skilled and unskilled manual workers, and farmers and self-employed combined. Inequalities were quantified with mortality rate ratios, rate differences, and population attributable fractions (PAF). Relative and absolute inequalities in all-cause mortality were more pronounced in Finland, Denmark, France, and Lithuania than in other populations, and the same countries (except France) also had the highest PAF values for all-cause mortality. The main contributing causes to these larger inequalities differed strongly between countries (e.g., cancer in France, all other causes in Denmark). Relative and absolute inequalities in CVD mortality were markedly lower in Southern European populations. We conclude that relative and absolute occupational class differences in all-cause and cause specific mortality have persisted into the early 2000's, although the magnitude differs strongly between populations. Comparisons with previous studies suggest that the relative gap in mortality between occupational classes has further widened in some Northern and Western European populations.

Although higher education has been associated with lower mortality rates in many studies, the effect of potential improvements in educational distribution on future mortality levels is unknown. We therefore estimated the impact of projected increases in higher education on mortality in European populations. We used mortality and population data according to educational level from 21 European populations and developed counterfactual scenarios. The first scenario represented the improvement in the future distribution of educational attainment as expected on the basis of an assumption of cohort replacement. We estimated the effect of this counterfactual scenario on mortality with a 10-15-year time horizon among men and women aged 30-79 years using a specially developed tool based on population attributable fractions (PAF). We compared this with a second, upward levelling scenario in which everyone has obtained tertiary education. The reduction of mortality in the cohort replacement scenario ranged from 1.9 to 10.1% for men and from 1.7 to 9.0% for women. The reduction of mortality in the upward levelling scenario ranged from 22.0 to 57.0% for men and from 9.6 to 50.0% for women. The cohort replacement scenario was estimated to achieve only part (4-25% (men) and 10-31% (women)) of the potential mortality decrease seen in the upward levelling scenario. We concluded that the effect of on-going improvements in educational attainment on average mortality in the population differs across Europe, and can be substantial. Further investments in education may have important positive side-effects on population health., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: While educational inequalities in mortality are substantial in most European countries, they are relatively small in Spain. A better understanding of the causes of these smaller inequalities in Spain may help to develop policies to reduce inequalities in mortality elsewhere. The aim of the present study was therefore to identify the specific causes of death and determinants contributing to these smaller inequalities., Methods: Data on mortality by education were obtained from longitudinal mortality studies in three Spanish populations (Barcelona, Madrid, the Basque Country), and six other Western European populations. Data on determinants by education were obtained from health interview surveys., Results: The Spanish populations have considerably smaller absolute inequalities in mortality than other Western European populations. This is due mainly to smaller inequalities in mortality from cardiovascular disease (men) and cancer (women). Inequalities in mortality from most other causes are not smaller in Spain than elsewhere. Spain also has smaller inequalities in smoking and sedentary lifestyle and this is due to more smoking and physical inactivity in higher educated groups., Conclusion: Overall, the situation with regard to health inequalities does not appear to be more favourable in Spain than in other Western European populations. Smaller inequalities in mortality from cardiovascular disease and cancer in Spain are likely to be related to its later socio-economic modernization. Although these smaller inequalities in mortality seem to be a historical coincidence rather than the outcome of deliberate policies, the Spanish example does suggest that large inequalities in total mortality are not inevitable., (© The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)