How Can Inequalities in Mortality Be Reduced? A Quantitative Analysis of 6 Risk Factors in 21 European Populations

Abstract

BackgroundSocioeconomic 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.MethodsWe 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.FindingsIn 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.InterpretationTheoretically, 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.

Social Inequality in Cigarette Consumption, Cigarette Dependence, and Intention to Quit among Norwegian Smokers

“…Despite reduced mortality in all educational groups, educational inequality in mortality increased in Norway in the period 1960–2000 [ 9 ]. Smoking is one mechanism behind this inequality [ 10 ]. Increased knowledge about social inequality in smoking behaviour can inform tobacco prevention efforts.…”

Tobacco control policies and perinatal and child health: a systematic review and meta-analysis protocol

“…In order to inform policy deliberations in the field, we will, where possible, report outcomes according to the comprehensiveness and/or degree of coverage of the intervention (eg, type of environment covered for smoke-free legislation, degree of tobacco tax increase, stop-smoking medicines being free vs low-cost), in subgroup analyses. Furthermore, given the large and increasing global disparities in smoking and smoking-related health outcomes, 26 27 and the evidence of differential impact of various tobacco control policies on these disparities, 11 15 27 28 we will, where possible, report the impact of each intervention according to socioeconomic status, alongside describing its overall impact. In an attempt to further minimise potential residual confounding by active smoking among children, we will, where relevant, reanalyse the data after exclusion of studies with active smoking rates >10% in the study population.…”

29 recommendations to combat social inequalities in health. The Norwegian Council on Social Inequalities in Health

“…Health-promoting behaviour in all social groups (30,31,32,33,34,35,36,37) Bad health habits are more common in groups with a low social status Differences in health behaviour stem from unnecessary and unfair differences in social, economic and environmental living conditions. Today, most ill health in high-income countries such as Norway is caused by non-communicable diseases, and the risk factors for these disease groups are largely linked to unfavourable behaviours such as smoking, unhealthy diets, sedentary lifestyles, alcohol and drug use.…”