title: Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries.
abstract: 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.
authors: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
authors: Johan P
authors: JP
authors: Mackenbach
authors: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
authors: Ivana
authors: I
authors: Kulhánová
authors: Centre for research in Epidemiology and Population Health (CESP), U1018, INSERM, Villejuif, France University of Versailles Saint Quentin, Versailles, France.
authors: Gwenn
authors: G
authors: Menvielle
authors: Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland.
authors: Matthias
authors: M
authors: Bopp
authors: Agència de Salut Pública de Barcelona, Barcelona, Spain.
authors: Carme
authors: C
authors: Borrell
authors: Department of Clinical Medicine and Biology, University of Turin, Turin, Italy.
authors: Giuseppe
authors: G
authors: Costa
authors: Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium.
authors: Patrick
authors: P
authors: Deboosere
authors: Department of Public Health, Basque Government, Vitoria, Spain.
authors: Santiago
authors: S
authors: Esnaola
authors: Lithuanian University of Health Sciences, Kaunas, Lithuania.
authors: Ramune
authors: R
authors: Kalediene
authors: Demographic Research Institute of the Central Statistical Office, Budapest, Hungary.
authors: Katalin
authors: K
authors: Kovacs
authors: Stockholm Centre on Health of Societies in Transition, Södertörn University, Huddinge, Sweden Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia.
authors: Mall
authors: M
authors: Leinsalu
authors: Department of Sociology, University of Helsinki, Helsinki, Finland.
authors: Pekka
authors: P
authors: Martikainen
authors: Department of Preventive Medicine and Public Health, Universidad Complutense de Madrid, Madrid, Spain.
authors: Enrique
authors: E
authors: Regidor
authors: Agència de Salut Pública de Barcelona, Barcelona, Spain.
authors: Maica
authors: M
authors: Rodriguez-Sanz
authors: Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
authors: Bjørn Heine
authors: BH
authors: Strand
authors: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
authors: Rasmus
authors: R
authors: Hoffmann
authors: Department of Public Health, Erasmus MC, Rotterdam, The Netherlands Department of Sociology and Political Science, NTNU, Trondheim, Norway.
authors: Terje A
authors: TA
authors: Eikemo
authors: Center for Health Equity Studies, Stockholm, Sweden.
authors: Olof
authors: O
authors: Östergren
authors: Center for Health Equity Studies, Stockholm, Sweden Department of Health Sciences, Mid Sweden University, Östersund, Sweden.
authors: Olle
authors: O
authors: Lundberg
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D019973:Alcohol-Related Disorders / Q000401:mortality; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death / Q000639:trends*; D003431:Cross-Cultural Comparison; D004522:Educational Status; D005060:Europe / Q000453:epidemiology; D005260:Female; D015438:Health Behavior; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D061213:Mortality, Premature / Q000639:trends*; D009369:Neoplasms / Q000401:mortality; D017678:Sex Distribution; D012923:Social Class; D014029:Tobacco Use Disorder / Q000401:mortality
keywords: Inequalities; Mortality; Time-Series