dementia in general to any substantial extent. If anything, persistent smoking may increase rather than decrease the onset rate of dementia, but any net effect on severe dementia cannot be large in either direction.We thank the British doctors some of whom have continued to collaborate in this prospective study of their health for almost half a century, Robert Clarke, Rory Collins, and Christina Davies for their comments, and Cathy Harwood and Gale Mead for preparing the manuscript.Contributors: RD planned the study, IS has for many years conducted it, and RD, RP, and JB planned and conducted the present analyses. RD and RP prepared the report; they will act as guarantors for the paper.Funding: The Medical Research Council has supported the study since 1951 and continues to do so through direct support of the Clinical Trial Service Unit and Epidemiological Studies Unit, helped by the Imperial Cancer Research Fund and British Heart Foundation.Competing interests: None declared. Main outcome measures Relative differences (odds ratios) and absolute differences in the prevalence of ever smoking and current smoking for men and women in each age group by educational level. Results In the 45 to 74 year age group, higher rates of current and ever smoking among lower educated subjects were found in some countries only. Among women this was found in Great Britain, Norway, and Sweden, whereas an opposite pattern, with higher educated women smoking more, was found in southern Europe. Among men a similar north-south pattern was found but it was less noticeable than among women. In the 20 to 44 year age group, educational differences in smoking were generally greater than in the older age group, and smoking rates were higher among lower educated people in most countries. Among younger women, a similar north-south pattern was found as among older women. Among younger men, large educational differences in smoking were found for northern European as well as for southern European countries, except for Portugal. Conclusions These international variations in social gradients in smoking, which are likely to be related to differences between countries in their stage of the smoking epidemic, may have contributed to the socioeconomic differences in mortality from ischaemic heart disease being greater in northern European countries. The observed age patterns suggest that socioeconomic differences in diseases related to smoking will increase in the coming decades in many European countries. IntroductionSocioeconomic inequalities in health have been found in all countries where data are available, and there is an Until now only a few studies have compared the magnitude of socioeconomic differences in smoking between countries. [5][6][7] The most comprehensive comparison described differences in prevalence of smoking by educational level in the United Kingdom, Finland, Sweden, Norway, and France around 1987. 6 In all these countries, lower educated people smoked more than higher educated people. The largest differences were observed in ...

Study objective-To assess whether there are variations between 11 Western European countries with respect to the size of diVerences in self reported morbidity between people with high and low educational levels. Design and methods-National representative data on morbidity by educational level were obtained from health interview surveys, level of living surveys or other similar surveys carried out between 1985 and 1993. Four morbidity indicators were included and a considerable eVort was made to maximise the comparability of these indicators. A standardised scheme of educational levels was applied to each survey. The study included men and women aged 25 to 69 years. The size of morbidity diVerences was measured by means of the regression based Relative Index of Inequality. Main results-The size of inequalities in health was found to vary between countries. In general, there was a tendency for inequalities to be relatively large in Sweden, Norway, and Denmark and to be relatively small in Spain, Switzerland, and West Germany. Intermediate positions were observed for Finland, Great Britain, France, and Italy. The position of the Netherlands strongly varied according to sex: relatively large inequalities were found for men whereas relatively small inequalities were found for women. The relative position of some countries, for example, West Germany, varied according to the morbidity indicator. Conclusions-Because of a number of unresolved problems with the precision and the international comparability of the data, the margins of uncertainty for the inequality estimates are somewhat wide. However, these problems are unlikely to explain the overall pattern. It is remarkable that health inequalities are not necessarily smaller in countries with more egalitarian policies such as the Netherlands and the Scandinavian countries. Possible explanations are discussed.(J Epidemiol Community Health 1998;52: [219][220][221][222][223][224][225][226][227] Many studies throughout Europe have reported a higher level of morbidity and mortality for people with a lower educational level, occupational status or income level.1-3 An interesting question is whether the size of these health inequalities varies substantially between countries. One of the reasons for studying international variations in socioeconomic inequalities is that international comparison enables judgements to be made on the size of inequalities in health in diVerent country. In addition, comparative studies of health inequalities in societies that diVer with respect to the size of income inequalities, national living standards, and other potentially relevant aspects, may shed more light on the causes of socioeconomic inequalities in health.Several international comparisons have focused on socioeconomic inequalities in self reported morbidity. These studies suggested that the size of inequalities in health varies between countries. [4][5][6][7][8][9][10][11][12][13][14][15] Comparative research has, however, until now lacked comprehensiveness and often suVered f...

The persistence of international differences in average height into the youngest birth cohorts indicates a high degree of continuity of differences between countries in childhood living conditions. Similarly, the persistence of education-related height differences indicates continuity of socio-economic differences in childhood living conditions, and also suggests that socio-economic differences in childhood living conditions will continue to contribute to socio-economic differences in health at adult ages.

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Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from 1980 to 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from 2002 to 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

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. MethodsWe 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.

The magnitude of socioeconomic inequalities in mortality differs importantly between countries, but these variations have not been satisfactorily explained. We explored the role of behavioral and structural determinants of these variations, by using a dataset covering 17 European countries in the period 1970-2010, and by conducting multilevel multivariate regression analyses. Our results suggest that between-country variations in inequalities in current mortality can partly be understood from variations in inequalities in smoking, excessive alcohol consumption, and poverty. Also, countries with higher national income, higher quality of government, higher social transfers, higher health care expenditure and more self-expression values have smaller inequalities in mortality. Finally, trends in behavioral risk factors, particularly smoking and excessive alcohol consumption, appear to partly explain variations in inequalities in mortality trends. This study shows that analyses of variations in health inequalities between countries can help to identify entry-points for policy.

OBJECTIVES: Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences. METHODS: Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively. RESULTS: A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years). CONCLUSIONS: The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.