Modifiable causes of premature death in middle-age in Western Europe: results from the EPIC cohort study.
BACKGROUND
Life expectancy is increasing in Europe, yet a substantial proportion of adults still die prematurely before the age of 70 years. We sought to estimate the joint and relative contributions of tobacco smoking, hypertension, obesity, physical inactivity, alcohol and poor diet towards risk of premature death.


METHODS
We analysed data from 264,906 European adults from the EPIC prospective cohort study, aged between 40 and 70 years at the time of recruitment. Flexible parametric survival models were used to model risk of death conditional on risk factors, and survival functions and attributable fractions (AF) for deaths prior to age 70 years were calculated based on the fitted models.


RESULTS
We identified 11,930 deaths which occurred before the age of 70. The AF for premature mortality for smoking was 31 % (95 % confidence interval (CI), 31-32 %) and 14 % (95 % CI, 12-16 %) for poor diet. Important contributions were also observed for overweight and obesity measured by waist-hip ratio (10 %; 95 % CI, 8-12 %) and high blood pressure (9 %; 95 % CI, 7-11 %). AFs for physical inactivity and excessive alcohol intake were 7 % and 4 %, respectively. Collectively, the AF for all six risk factors was 57 % (95 % CI, 55-59 %), being 35 % (95 % CI, 32-37 %) among never smokers and 74 % (95 % CI, 73-75 %) among current smokers.


CONCLUSIONS
While smoking remains the predominant risk factor for premature death in Europe, poor diet, overweight and obesity, hypertension, physical inactivity, and excessive alcohol consumption also contribute substantially. Any attempt to minimise premature deaths will ultimately require all six factors to be addressed.
International Agency for Research on Cancer, 69008, Lyon, France.
David C
DC
Muller
School of Public Health, Imperial College London, London, SW7 2AZ, UK.
Neil
N
Murphy
International Agency for Research on Cancer, 69008, Lyon, France.
Mattias
M
Johansson
International Agency for Research on Cancer, 69008, Lyon, France.
Pietro
P
Ferrari
Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, 45110, Ioannina, Greece.|Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, SW7 2AZ, UK.
Konstantinos K
KK
Tsilidis
Centre for Research in Epidemiology and Population Health (CESP), 94805, Villejuif, France.|Université Paris Sud, Villejuif, France.|Institut Gustave Roussy, Villejuif, France.
Marie-Christine
MC
Boutron-Ruault
Université Paris Sud, Villejuif, France.|Institut Gustave Roussy, Villejuif, France.|Inserm, Centre for Research in Epidemiology and Population Health (CESP), 94805, Villejuif, France.
Francoise
F
Clavel
Université Paris Sud, Villejuif, France.|Institut Gustave Roussy, Villejuif, France.|Inserm, Centre for Research in Epidemiology and Population Health (CESP), 94805, Villejuif, France.
Laureen
L
Dartois
Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), DE-69120, Heidelberg, Germany.
Kuanrong
K
Li
Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), DE-69120, Heidelberg, Germany.
Rudolf
R
Kaaks
German Institute of Human Nutrition Potsdam-Rehbrücke (DifE), DE-14558, Nuthetal, Germany.
Cornelia
C
Weikert
German Institute of Human Nutrition Potsdam-Rehbrücke (DifE), DE-14558, Nuthetal, Germany.
Manuela
M
Bergmann
German Institute of Human Nutrition Potsdam-Rehbrücke (DifE), DE-14558, Nuthetal, Germany.
Heiner
H
Boeing
Danish Cancer Society Research Center, DK-2100, Copenhagen, Denmark.
Anne
A
Tjønneland
Department of Public Health, Section for Epidemiology, Aarhus University, DK-8000, Aarhus, Denmark.
Kim
K
Overvad
Public Health Directorate, 33006, Asturias, Spain.
M Luisa
ML
Redondo
Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Program, Catalan Institute of Oncology, 08908, Barcelona, Spain.
Antonio
A
Agudo
Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria GRANADA, Hospitales Universitarios de Granada/Universidad de Granada, 18012, Granada, Spain.|Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.
Elena
E
Molina-Portillo
Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.|Public Health Division of Gipuzkoa-BIODONOSTIA, Basque Regional Health Department, 20014, Donostia - San Sebastián, Spain.
Jone M
JM
Altzibar
Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.|Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, 30003, Murcia, Spain.|Department of Health and Social Sciences, Universidad de Murcia, Murcia, Spain.
Lluís
L
Cirera
Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.|Navarra Public Health Institute, 31003, Pamplona, Spain.|Navarra Institute for Health Research (IdiSNA) Pamplona, Pamplona, Spain.
Eva
E
Ardanaz
School of Clinical Medicine, University of Cambridge, Cambridge, CB2 2QQ, UK.
Kay-Tee
KT
Khaw
MRC Epidemiology Unit, University of Cambridge, Cambridge, CB2 0SR, UK.
Nicholas J
NJ
Wareham
Cancer Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK.
Timothy J
TJ
Key
Cancer Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK.
Ruth C
RC
Travis
Hellenic Health Foundation, GR-115 27, Athens, Greece.|Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece.
Christina
C
Bamia
Hellenic Health Foundation, GR-115 27, Athens, Greece.|Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece.
Philippos
P
Orfanos
Hellenic Health Foundation, GR-115 27, Athens, Greece.|Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, Athens, Greece.
Antonia
A
Trichopoulou
Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), 50134, Florence, Italy.
Domenico
D
Palli
Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133, Milan, Italy.
Valeria
V
Pala
Cancer Registry and Histopathology Unit, "Civic - M. P. Arezzo" Hospital, ASP Ragusa, Ragusa, 97100, Italy.
Rosario
R
Tumino
School of Public Health, Imperial College London, London, SW7 2AZ, UK.|Human Genetics Foundation (HuGeF), Torino, Italy.
Paolo
P
Vineis
Dipartimento di Medicina Clinica e Sperimentale, Federico II University, 80138, Naples, Italy.
Salvatore
S
Panico
School of Public Health, Imperial College London, London, SW7 2AZ, UK.|Department for Determinants of Chronic Diseases (DCD), National Institute for Public Health and the Environment (RIVM), 3720 BA, Bilthoven, The Netherlands.|Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands.|Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
H Bas
HB
Bueno-de-Mesquita
Department for Determinants of Chronic Diseases (DCD), National Institute for Public Health and the Environment (RIVM), 3720 BA, Bilthoven, The Netherlands.|Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
W M Monique
WM
Verschuren
Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Ellen A
EA
Struijk
School of Public Health, Imperial College London, London, SW7 2AZ, UK.|Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Petra H
PH
Peeters
Department of Clinical Science, Malmö Lund University, Lund, SE-205 02, Sweden.
Gunnar
G
Engström
Department of Clinical Sciences, Hypertension & Cardiovascular Disease, Clinical Research Centre, Malmö University Hospital, SE-20502, Malmö, Sweden.
Olle
O
Melander
Department of Surgical and Perioperative Sciences, Umea University, 901 85, Umea, Sweden.
Malin
M
Sund
Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037, Tromsø, Norway.|Department of Research, Cancer Registry of Norway, Oslo, Norway.|Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.|Samfundet Folkhälsan, Helsinki, Finland.
Elisabete
E
Weiderpass
Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037, Tromsø, Norway.|The Arctic University of Norway, Tromsø, Norway.
Guri
G
Skeie
Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, 9037, Tromsø, Norway.|The Arctic University of Norway, Tromsø, Norway.
Eiliv
E
Lund
School of Public Health, Imperial College London, London, SW7 2AZ, UK.
Teresa
T
Norat
School of Public Health, Imperial College London, London, SW7 2AZ, UK.
Marc
M
Gunter
School of Public Health, Imperial College London, London, SW7 2AZ, UK.
Elio
E
Riboli
International Agency for Research on Cancer, 69008, Lyon, France. gep@iarc.fr.
Paul
P
Brennan
D000328:Adult; D000368:Aged; D000428:Alcohol Drinking / Q000009:adverse effects / Q000401:mortality; D015331:Cohort Studies; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000401:mortality; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D061213:Mortality, Premature; D009043:Motor Activity; D009765:Obesity / Q000150:complications / Q000401:mortality; D011446:Prospective Studies; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects / Q000401:mortality
Absolute risk; Attributable fraction; Modifiable risk factors; Mortality; Premature death