Smoking and the potential for reduction of inequalities in mortality in Europe.

Margarete Christine Kulik, Rasmus Hoffmann, Ken Judge, Caspar Looman, Gwenn Menvielle, Ivana Kulhánová, Marlen Toch, Olof Östergren, Pekka Martikainen, Carme Borrell, Maica Rodríguez-Sanz, Matthias Bopp, Mall Leinsalu, Domantas Jasilionis, Johan P. Mackenbach 2014. European Journal of Epidemiology, 28(12), 959-971.

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Mortality rate ratios come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and COPD/asthma. We use a newly-developed tool to quantify the changes in population health potentially
resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the Population Attributable Fraction, and estimates the impact of  scenario-based distributions of smoking on educational inequalities in mortality.
The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26% for men and 32% for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe. The patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entrypoint for tackling health inequalities should differ between countries.