J Epidemiol Community Health 67:603-609 doi:10.1136/jech-2012-201716
  • Research reports

Educational inequalities in mortality in northern, mid and southern Italy and the contribution of smoking

  1. Anton E Kunst6
  1. 1Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Cassino, Italy
  2. 2Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
  3. 3National Institute of Statistics, Rome, Italy
  4. 4Local Health Unit TO3, Turin, Italy
  5. 5Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
  6. 6Department of Public Health, Academic Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Dr Bruno Federico, Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, via Sant'Angelo snc, Cassino 03043, Italy; b.federico{at}
  • Received 5 July 2012
  • Revised 15 January 2013
  • Accepted 26 March 2013
  • Published Online First 17 April 2013


Background Previous studies have shown that mortality inequalities are smaller in Italy than in most European countries. This may be due to the weak association between socioeconomic status and smoking in Italy. However, most published studies were based on data from a single city in northern Italy (Turin). In this study, we aimed to assess the size of mortality inequalities in Italy as a whole, their geographical pattern of variation within Italy, and the contribution of smoking to these inequalities.

Methods Participants in the National Health Interview Survey 1999–2000 were followed up for mortality until 31 December 2007. Using Cox regression, we computed the age-adjusted relative index of inequality (RII) for all-cause mortality with and without controlling for smoking status and intensity. Education was used as an indicator of socioeconomic status.

Results Among 72 762 individuals aged 30–74 years at baseline, 4092 died during the follow-up. The age-adjusted RII of mortality was 1.69 (95% CI 1.44 to 2.00) among men and 1.43 (95% CI 1.13 to 1.82) among women. Among men, inequalities were larger in both northern and southern regions than in the middle of the country, whereas among women they were larger in the south. After controlling for smoking RII decreased to 1.63 (95% CI 1.38 to 1.92) among men and increased to 1.54 (95% CI 1.21 to 1.96) among women. The geographical variation in mortality inequalities was not affected by smoking adjustment.

Conclusions Mortality inequalities in Italy are smaller than in most European countries. This is due, among other factors, to the weak socioeconomic pattern of smoking over the past decades in Italy.