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Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries
  1. Johan P Mackenbach1,
  2. Ivana Kulhánová1,
  3. Gwenn Menvielle2,3,
  4. Matthias Bopp4,
  5. Carme Borrell5,
  6. Giuseppe Costa6,
  7. Patrick Deboosere7,
  8. Santiago Esnaola8,
  9. Ramune Kalediene9,
  10. Katalin Kovacs10,
  11. Mall Leinsalu11,12,
  12. Pekka Martikainen13,
  13. Enrique Regidor14,
  14. Maica Rodriguez-Sanz5,
  15. Bjørn Heine Strand15,
  16. Rasmus Hoffmann1,
  17. Terje A Eikemo1,16,
  18. Olof Östergren17,
  19. Olle Lundberg17,18
  20. for the Eurothine and EURO-GBD-SE consortiums
  1. 1Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
  2. 2Centre for research in Epidemiology and Population Health (CESP), U1018, INSERM, Villejuif, France
  3. 3University of Versailles Saint Quentin, Versailles, France
  4. 4Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland
  5. 5Agència de Salut Pública de Barcelona, Barcelona, Spain
  6. 6Department of Clinical Medicine and Biology, University of Turin, Turin, Italy
  7. 7Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
  8. 8Department of Public Health, Basque Government, Vitoria, Spain
  9. 9Lithuanian University of Health Sciences, Kaunas, Lithuania
  10. 10Demographic Research Institute of the Central Statistical Office, Budapest, Hungary
  11. 11Stockholm Centre on Health of Societies in Transition, Södertörn University, Huddinge, Sweden
  12. 12Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
  13. 13Department of Sociology, University of Helsinki, Helsinki, Finland
  14. 14Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Madrid, Spain
  15. 15Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
  16. 16Department of Sociology and Political Science, NTNU, Trondheim, Norway
  17. 17Center for Health Equity Studies, Stockholm, Sweden
  18. 18Department of Health Sciences, Mid Sweden University, Östersund, Sweden
  1. Correspondence to Professor J P Mackenbach, Department of Public Health, Erasmus MC, P.O. Box 2040, Rotterdam 3000 CA, The Netherlands; j.mackenbach{at}


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.

  • Mortality
  • Inequalities
  • Time-Series

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