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.

pdf/changes-in-mortality-inequalities-over-two-decades-register-1zjojvexxx.pdf

Changes in mortality inequalities over two decades: register based study of European countries.

Comparisons among countries can help to identify opportunities for the reduction of inequalities in health. We compared the magnitude of inequalities in mortality and self-assessed health among 22 countries in all parts of Europe.

Socioeconomic Inequalities in Health in 22 European Countries

Summary Background Socioeconomic inequalities in longevity have been found in all European countries. We aimed to assess which determinants make the largest contribution to these inequalities. Methods We did an international comparative study of inequalities in risk factors for shorter life expectancy in Europe. We collected register-based mortality data and survey-based risk factor data from 15 European countries. We calculated partial life expectancies between the ages of 35 years and 80 years by education and gender and determined the effect on mortality of changing the prevalence of eight risk factors—father with a manual occupation, low income, few social contacts, smoking, high alcohol consumption, high bodyweight, low physical exercise, and low fruit and vegetable consumption—among people with a low level of education to that among people with a high level of education (upward levelling scenario), using population attributable fractions. Findings In all countries, a substantial gap existed in partial life expectancy between people with low and high levels of education, of 2·3–8·2 years among men and 0·6–4·5 years among women. The risk factors contributing most to the gap in life expectancy were smoking (19·8% among men and 18·9% among women), low income (9·7% and 13·4%), and high bodyweight (7·7% and 11·7%), but large differences existed between countries in the contribution of risk factors. Sensitivity analyses using the prevalence of risk factors in the most favourable country (best practice scenario) showed that the potential for reducing the gap might be considerably smaller. The results were also sensitive to varying assumptions about the mortality risks associated with each risk factor. Interpretation Smoking, low income, and high bodyweight are quantitatively important entry points for policies to reduce educational inequalities in life expectancy in most European countries, but priorities differ between countries. A substantial reduction of inequalities in life expectancy requires policy actions on a broad range of health determinants. Funding European Commission and Network for Studies on Pensions, Aging, and Retirement.

https://www.zora.uzh.ch/id/eprint/175404/1/determinants-mackenbach.pdf

Determinants of inequalities in life expectancy : an international comparative study of eight risk factors

https://repub.eur.nl/pub/101094/REPUB_101094-OA.pdf

Determinants of the magnitude of socioeconomic inequalities in mortality: A study of 17 European countries

The aim of this study was to investigate long-term trends in smoking prevalence and its socioeconomic inequalities in Korea. Data were collected from 10 rounds of the Social Survey of Statistics Korea between 1992 and 2016. A total of 524,866 men and women aged 19 or over were analyzed. Age-adjusted smoking prevalence was calculated according to three major socioeconomic position indicators: education, occupational class, and income. The prevalence difference, prevalence ratio, slope index of inequality (SII), and relative index of inequality (RII) were calculated to examine the magnitude of inequality in smoking. Smoking prevalence among men decreased from 71.7% in 1992 to 39.7% in 2016, while smoking prevalence among women decreased from 6.5% in 1992 to 3.3% in 2016. Socioeconomic inequalities in smoking prevalence according to the three socioeconomic position indicators were found in both men and women throughout the study period. In general, absolute and relative socioeconomic inequalities in smoking, measured by prevalence difference and prevalence ratio for education and occupational class, widened during the study period among Korean men and women. In men, the SII for income increased from 7.6% in 1999 to 10.8% in 2016 and the RII for income also increased from 1.11 in 1999 to 1.31 in 2016. In women, the SII for income increased from 0.1% in 1999 to 2.4% in 2016 and the RII for income increased from 1.39 in 1999 to 2.25 in 2016. Pro-rich socioeconomic inequalities in smoking prevalence were found in men and women. Socioeconomic inequalities in smoking have increased in parallel with the implementation of tobacco control policies. Tobacco control policies should be developed to decrease socioeconomic inequalities in cigarette use in Korea.

/pdf/long-term-trends-in-smoking-prevalence-and-its-socioeconomic-o5h4djvbdt.pdf

Long-term trends in smoking prevalence and its socioeconomic inequalities in Korea, 1992-2016.

/pdf/the-contribution-of-smoking-to-socio-economic-inequalities-40yqt1v9mn.pdf

The contribution of smoking to socio-economic inequalities in mortality in 13 European countriesGiorgia Gregoraci

Background Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990–1994 and 2000–2004 in 14 European countries. Methods We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990–1994 and 2000–2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method. Results In 2000–2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between −1% and 56% among women. Since 1990–1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women. Conclusions In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

https://tobaccocontrol.bmj.com/content/tobaccocontrol/26/3/260.full.pdf

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990–2004

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The contribution of smoking to socio-economic inequalities in mortality in 13 European countriesGiorgia Gregoraci

Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990–2004