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  • 1.
    Altmejd, Adam
    et al.
    Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Björkegren, Evelina
    Stockholm University, Faculty of Social Sciences, Department of Economics.
    Persson, Torsten
    Stockholm University, Faculty of Social Sciences, Institute for International Economic Studies. London School of Economics, London, United Kingdon.
    Inequality and COVID-19 in Sweden: Relative risks of nine bad life events, by four social gradients, in pandemic vs. prepandemic years2023In: Proceedings of the National Academy of Sciences of the United States of America, ISSN 0027-8424, E-ISSN 1091-6490, Vol. 120, no 46, article id e2303640120Article in journal (Refereed)
    Abstract [en]

    The COVID-19 pandemic struck societies directly and indirectly, not just challenging population health but disrupting many aspects of life. Different effects of the spreading virus—and the measures to fight it—are reported and discussed in different scientific fora, with hard-to-compare methods and metrics from different traditions. While the pandemic struck some groups more than others, it is difficult to assess the comprehensive impact on social inequalities. This paper gauges social inequalities using individual-level administrative data for Sweden’s entire population. We describe and analyze the relative risks for different social groups in four dimensions—gender, education, income, and world region of birth—to experience three types of COVID-19 incidence, as well as six additional negative life outcomes that reflect general health, access to medical care, and economic strain. During the pandemic, the overall population faced severe morbidity and mortality from COVID-19 and saw higher all-cause mortality, income losses and unemployment risks, as well as reduced access to medical care. These burdens fell more heavily on individuals with low income or education and on immigrants. Although these vulnerable groups experienced larger absolute risks of suffering the direct and indirect consequences of the pandemic, the relative risks in pandemic years (2020 and 2021) were conspicuously similar to those in prepandemic years (2016 to 2019)

  • 2. Brønnum-Hansen, Henrik
    et al.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Tarkiainen, Lasse
    Hermansen, Åsmund
    Martikainen, Pekka
    van der Wel, Kjetil A.
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Changes in life expectancy and lifespan variability by income quartiles in four Nordic countries: a study based on nationwide register data2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 6, article id e048192Article in journal (Refereed)
    Abstract [en]

    Objectives Levels, trends or changes in socioeconomic mortality differentials are typically described in terms of means, for example, life expectancies, but studies have suggested that there also are systematic social disparities in the dispersion around those means, in other words there are inequalities in lifespan variation. This study investigates changes in income inequalities in mean and distributional measures of mortality in Denmark, Finland, Norway, and Sweden over two decades.

    Design Nationwide register-based study.

    Setting The Danish, Finnish, Norwegian and Swedish populations aged 30 years or over in 1997 and 2017.

    Main outcome measures Income-specific changes in life expectancy, lifespan variation and the contribution of 'early' and 'late' deaths to increasing life expectancy.

    Results Increases in life expectancy has taken place in all four countries, but there are systematic differences across income groups. In general, the largest gains in life expectancy were observed in Denmark, and the smallest increase among low-income women in Sweden and Norway. Overall, life expectancy increased and lifespan variation decreased with increasing income level. These differences grew larger over time. In all countries, a marked postponement of early deaths led to a compression of mortality in the top three income quartiles for both genders. This did not occur for the lowest income quartile.

    Conclusion Increasing life expectancy is typically accompanied by postponement of early deaths and reduction of lifespan inequality in the higher-income groups. However, Nordic welfare societies are challenged by the fact that postponing premature deaths among people in the lowest-income groups is not taking place.

  • 3. Elstad, Jon Ivar
    et al.
    Hermansen, Åsmund
    Brønnum-Hansen, Henrik
    Martikainen, Pekka
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Tarkiainen, Lasse
    Income security in Nordic welfare states for men and women who died when aged 55–69 years old2019In: Journal of International and Comparative Social Policy, ISSN 2169-9763, E-ISSN 2169-978X, Vol. 35, no 2, p. 157-176Article in journal (Refereed)
    Abstract [en]

    Income security when health impairment or other social risks occur is a major objective of welfare states. This comparative study uses register data from four Nordic welfare states for examining equivalized disposable income during the last 12 years alive among men and women who died when aged 55–69 years old. The analysed outcome indicates the aggregate result of a varied set of income maintenance mechanisms. Median income increased in the Finnish, Norwegian and Swedish samples, but decreased somewhat in Denmark, probably due to relatively frequent transitions to retirement and larger income drops after retirement than in the other Nordic countries. Analyses of comparison samples weighted by propensity scores indicated a better income development among those who lived beyond the observation period than among those who died. The higher educated had a more favourable income development during the years prior to death than those with low education.

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  • 4.
    Gauffin, Karl
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Östergren, Olof
    Department of Public Health Sciences, Stockholm University , Stockholm, Sweden;Aging Research Center (ARC), Karolinska Institutet , Solna, Sweden.
    Cederström, Agneta
    Department of Public Health Sciences, Stockholm University , Stockholm, Sweden.
    Waves of inequality: income differences in intensive care due to Covid-19 in Sweden2023In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 33, no 4, p. 574-579Article in journal (Refereed)
    Abstract [en]

    Background: Socioeconomically vulnerable groups were overall more likely to develop severe Covid-19, but specific conditions in terms of preparedness, knowledge and the properties of the virus itself changed during the course of the pandemic. Inequalities in Covid-19 may therefore shift over time. This study examines the relationship between income and intensive care (ICU) episodes due to Covid-19 in Sweden during three distinct waves.

    Methods: This study uses Swedish register data on the total adult population and estimates the relative risk (RR) of ICU episodes due to Covid-19 by income quartile for each month between March 2020 and May 2022, and for each wave, using Poisson regression analyses.

    Results: The first wave had modest income-related inequalities, while the second wave had a clear income gradient, with the lowest income quartile having an increased risk compared to the high-income group [RR: 1.55 (1.36–1.77)]. In the third wave, the overall need for ICU decreased, but RRs increased, particularly in the lowest income quartile [RR: 3.72 (3.50–3.96)]. Inequalities in the third wave were partly explained by differential vaccination coverage by income quartile, although substantial inequalities remained after adjustment for vaccination status [RR: 2.39 (2.20–2.59)].

    Conclusions: The study highlights the importance of considering the changing mechanisms that connect income and health during a novel pandemic. The finding that health inequalities increased as the aetiology of Covid-19 became better understood could be interpreted through the lens of adapted fundamental cause theory.

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    Gauffin et al 2023
  • 5.
    Gurzo, Klara
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Max Planck Institute for Demographic Research, Germany.
    Modin, Bitte
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Max Planck Institute for Demographic Research, Germany; University of Helsinki, Finland.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Pathways from Childhood Economic Conditions to Adult Mortality in a 1953 Stockholm Cohort: The Intermediate Role of Personal Attributes and Socioeconomic Career2022In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 19, no 12, article id 7279Article in journal (Refereed)
    Abstract [en]

    Although both childhood and adult economic conditions have been found to be associated with mortality, independently or in combination with each other, less is known about the role of intermediate factors between these two life stages. This study explores the pathways between childhood economic conditions and adult mortality by taking personal attributes as well as adult socioeconomic career into consideration. Further, we investigate the role of intergenerational income mobility for adult mortality. We used data from a prospective cohort study of individuals that were born in 1953 and residing in Stockholm, Sweden, in 1963 who were followed for mortality between 2002 and 2021 (n = 11,325). We fit Cox proportional hazards models to assess the association of parental income, cognitive ability, social skills, educational attainment, occupational status, and adult income with mortality. The income mobility is operationalized as the interaction between parental and adult income. Our results show that the association between parental income and adult mortality is modest and largely operates through cognitive ability and adult educational attainment. However, our results do not provide support for there being an effect of intergenerational income mobility on adult mortality. In a Swedish cohort who grew up in a comparatively egalitarian society during the 1950s and 1960s, childhood economic conditions were found to play a distinct but relatively small role for later mortality.

  • 6.
    Gurzo, Klara
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Rehnberg, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    One generation apart: Individual income and life expectancy in two Swedish cohorts born before and after the expansion of the welfare state2024In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    Aims: Social inequalities in mortality persist or even increase in high-income countries. Most evidence is based on a period approach to measuring mortality – that is, data from individuals born decades apart. A cohort approach, however, provides complementary insights using data from individuals who grow up and age under similar social and institutional arrangements. This study compares income inequalities in cohort life expectancy in two Swedish cohorts, one born before and one born after the expansion of the welfare state. Methods: Data on individuals born in Sweden in 1922–1926 and 1951–1955 were obtained from total population registries. These data were linked to individual disposable income from 1970 and 1999 and mortality between 50 and 61 years of age in 1972–1987 and 2001–2016, respectively. We calculated cohort temporary life expectancies in the two cohorts by income and gender. Results: Life expectancy, income, and income inequalities in life expectancy increased between the two cohorts, for both men and women. Women born in 1922–1926 had modest income differences in life expectancy, but pronounced differences emerged in the cohort born in 1951–1955. Men with low incomes born in 1951–1955 had roughly similar life expectancy as those with low incomes born in 1922–1926. Conclusions: Compared with a period approach to life expectancy trends, the cohort approach highlights the stagnation of mortality at the lowest income groups for men and the rapid emergence of a mortality gradient for women. Future research on health inequalities in welfare states should consider underlying factors both from a cohort and period perspective.

  • 7.
    Gurzo, Klara
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Modin, Bitte
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    The Impact of Privileged Classroom Friends on Adult Income and Income Mobility: A Study of a Swedish Cohort Born in 1953 2023In: Social Forces, ISSN 0037-7732, E-ISSN 1534-7605, Vol. 102, no 3, p. 1068-1088Article in journal (Refereed)
    Abstract [en]

    Social relationships across and within generations are associated with intergenerational income mobility. Parents affect their children’s future opportunities through socialization and by conveying various resources to the child during upbringing. However, self-acquired social contacts of children, such as friendships in school, might also affect long-term outcomes. Children from less privileged homes may gain access to additional resources through contact with privileged friends and their parents. This study examines whether having a classroom friend with high parental income (privileged friend) is associated with upward income mobility. Furthermore, it explores where in the parental income distribution a privileged friend matters most. We use data from the Stockholm Birth Cohort Multigenerational Study (n = 10,641), which is a prospective study of individuals born in 1953 who lived in the greater Stockholm area in 1963. We fit classroom fixed-effects models to estimate the association between having a privileged childhood friend and adult income as well as parental income and adult income along with the interaction of privileged friend and parental income. Results show that cohort members who had a privileged classroom friend had higher adult income, and that this income gain was greater among those whose parents belonged to the lowest income quartile, compared with those whose parents had higher incomes. These results are robust to adjustments for childhood socioeconomic background, personal attributes, and adult educational attainment. Our findings indicate that having an economically privileged friend in the school class bolsters adult income and upward income mobility of children from families with low income.

  • 8. Herttua, Kimmo
    et al.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Influence of affordability of alcohol on educational disparities in alcohol-related mortality in Finland and Sweden: a time series analysis2017In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 71, no 12, p. 1168-1176Article in journal (Refereed)
    Abstract [en]

    Background: Prices of alcohol and income tend to influence how much people buy and consume alcohol. Price and income may be combined into one measure, affordability of alcohol. Research on the association between affordability of alcohol and alcohol-related harm is scarce. Furthermore, no research exists on how this association varies across different subpopulations. We estimated the effects of affordability of alcohol on alcohol-related mortality according to gender and education in Finland and Sweden.

    Methods: Vector-autoregressive time series modelling was applied to the quarter-annual aggregations of alcohol-related deaths and affordability of alcohol in Finland in 1988–2007 and in Sweden in 1991–2008. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. We calculated affordability of alcohol index using information on personal taxable income and prices of various types of alcohol.

    Results: Among Finnish men with secondary education,an increase of 1% in the affordability of total alcohol was associated with an increase of 0.028% (95% CI 0.004 to 0.053) in alcohol-related mortality. Similar associations were also found for affordability for various types of alcohol and for beer only in the lowest education group. We found few other significant positive associations for other subpopulations in Finland or Sweden. However, reverse associations were found among secondary-educated Swedish women.

    Conclusions: Overall, the associations between affordability of alcohol and alcohol-related mortality were relatively weak. Increased affordability of total alcoholic beverages was associated with higher rates of alcohol-related mortality only among Finnish men with secondary education.

  • 9. Hossin, Muhammad Zakir
    et al.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Fors, Stefan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Is the Association Between Late Life Morbidity and Disability Attenuated Over Time? Exploring the Dynamic Equilibrium of Morbidity Hypothesis2019In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368, Vol. 74, no 8, p. 97-106Article in journal (Refereed)
    Abstract [en]

    Objective:

    There is evidence suggesting that the prevalence of disability in late life has declined over time while the prevalence of chronic diseases has increased. The dynamic equilibrium of morbidity hypothesis suggests that these patterns are due to the attenuation of the morbidity-disability link over time. This study aimed to test this assumption empirically.

    Methods:

    Data were drawn from three repeated cross-sections of SWEOLD, a nationally representative survey of the Swedish population aged 77 years and older. Poisson regression models were fitted to assess the trends in the prevalence of Activities of Daily Living (ADL) disability, Instrumental ADL (IADL) disability, and selected groups of chronic conditions. The changes in the associations between chronic conditions and disabilities were examined on both multiplicative and additive scales.

    Results:

    Between 1992 and 2011, the prevalence of both ADL and IADL disabilities decreased whereas the prevalence of nearly all chronic morbidities increased. Significant attenuations of the morbidity-disability associations were found for cardiovascular diseases, metabolic disorders, poor lung function, and psychological distress.

    Discussion:

    In agreement with the dynamic equilibrium of morbidity hypothesis, this study concludes that the morbidity-disability associations among the Swedish older adults largely waned between 1992 and 2011.

  • 10. Junna, Liina M.
    et al.
    Tarkiainen, Lasse
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Jasilionis, Domantas
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Exploring the longevity advantage of doctorates in Finland and Sweden: The role of smoking- and alcohol-related causes of death2021In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 49, no 4, p. 419-422Article in journal (Refereed)
    Abstract [en]

    Aims: Tobacco smoking and alcohol use contribute to differences in life expectancy between individuals with primary, secondary and tertiary education. Less is known about the contribution of these risk factors to differences at higher levels of education. We estimate the contribution of smoking and alcohol use to the life-expectancy differences between the doctorates and the other tertiary-educated groups in Finland and in Sweden. Methods: We used total population data from Finland and Sweden from 2011 to 2015 to calculate period life expectancies at 40 years of age. We present the results by sex and educational attainment, the latter categorised as doctorate or licentiate degrees, or other tertiary. We also present an age and cause of death decomposition to assess the contribution of deaths related to smoking and alcohol. Results: In Finland, deaths related to smoking and alcohol constituted 48.6% of the 2.1-year difference in life expectancy between men with doctorate degrees and the other tertiary-educated men, and 22.9% of the 2.1-year difference between women, respectively. In Sweden, these causes account for 22.2% of the 1.9-year difference among men, and 55.7% of the 1.6-year difference among women, which in the latter case is mainly due to smoking. Conclusions: Individuals with doctorates tend to live longer than other tertiary-educated individuals. This difference can be partly attributed to alcohol consumption and smoking.

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  • 11. Korhonen, Kaarina
    et al.
    Moustgaard, Heta
    Tarkiainen, Lasse
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Costa, Giuseppe
    Urhoj, Stine Kjaer
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Contributions of specific causes of death by age to the shorter life expectancy in depression: a register-based observational study from Denmark, Finland, Sweden and Italy2021In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 295, p. 831-838Article in journal (Refereed)
    Abstract [en]

    Background: The reasons for the shorter life expectancy of people with depression may vary by age. We quantified the contributions of specific causes of death by age to the life-expectancy gap in four European countries.

    Methods: Using register-based cohort data, we calculated annual mortality rates in between 1993 and 2007 for psychiatric inpatients with depression identified from hospital-care registers in Denmark, Finland and Sweden, and between 2000 and 2007 for antidepressant-treated outpatients identified from medication registers in Finland and Turin, Italy. We decomposed the life-expectancy gap at age 15 years by age and cause of death.

    Results: The life-expectancy gap was especially large for psychiatric inpatients (12.1 to 21.0 years) but substantial also for antidepressant-treated outpatients (6.3 to 14.2 years). Among psychiatric inpatients, the gap was largely attributable to unnatural deaths below age 55 years. The overall contribution was largest for suicide in Sweden (43 to 45%) and Finland (37 to 40%). In Denmark, 'other diseases' (25 to 34%) and alcohol-attributable causes (10 to 18%) had especially large contributions. Among antidepressant-treated outpatients, largest contributions were observed for suicide (18% for men) and circulatory deaths (23% for women) in Finland, and cancer deaths in Turin (29 to 36%). Natural deaths were concentrated at ages above 65 years.

    Limitations: The indication of antidepressant prescription could not be ascertained from the medication registers.

    Conclusions: Interventions should be directed to self-harm and substance use problems among younger psychi-atric inpatients and antidepressant-treated young men. Rigorous monitoring and treatment of comorbid somatic conditions and disease risk factors may increase life expectancy for antidepressant-treated outpatients, especially women.

  • 12. Kulik, M. C.
    et al.
    Hoffmann, R.
    Judge, K.
    Looman, C.
    Menvielle, G.
    Kulhanova, I.
    Toch, M.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, P.
    Borrell, C.
    Rodriguez-Sanz, M.
    Bopp, M.
    Leinsalu, M.
    Jasilionis, D.
    Eikemo, T. A.
    Mackenbach, J. P.
    Smoking and the potential for reduction of inequalities in mortality in Europe2013In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 28, no 12, p. 959-971Article in journal (Refereed)
    Abstract [en]

    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. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/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 and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.

  • 13. Kulik, Margarete C
    et al.
    Menvielle, Gwenn
    Eikemo, Terje A
    Bopp, Matthias
    Jasilionis, Domantas
    Kulhánová, Ivana
    Leinsalu, Mall
    Martikainen, Pekka
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Mackenbach, Johan P
    Educational inequalities in three smoking-related causes of eeath in 18 European populations2014In: Nicotine & tobacco research, ISSN 1462-2203, E-ISSN 1469-994X, Vol. 16, no 5, p. 507-518Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Smoking is an important determinant of socioeconomic inequalities in mortality in many countries. As the smoking epidemic progresses, updates on the development of mortality inequalities attributable to smoking are needed. We provide estimates of relative and absolute educational inequalities in mortality from lung cancer, aerodigestive cancers, and chronic obstructive pulmonary disease (COPD)/asthma in Europe for the early 2000s and assess the contribution of these smoking-related diseases to inequalities in all-cause mortality.

    METHODS: We use data from 18 European populations covering the time period 1998-2007. We present age-adjusted mortality rates, relative indices of inequality, and slope indices of inequality. We also calculate the contribution of inequalities in smoking-related mortality to inequalities in overall mortality.

    RESULTS: Among men, relative inequalities in mortality from the 3 smoking-related causes of death combined are largest in the Czech Republic and Hungary and smallest in Spain, Sweden, and Denmark. Among women, these inequalities are largest in Scotland and Norway and smallest in Italy and Spain. They are often larger among men and tend to be larger for COPD/asthma than for lung and aerodigestive cancers. Relative inequalities in mortality from these conditions are often larger in younger age groups, particularly among women, suggesting a possible further widening of inequalities in mortality in the coming decades. The combined contribution of these diseases to inequality in all-cause mortality varies between 13% and 32% among men and between -5% and 30% among women.

    CONCLUSION: Our results underline the continuing need for tobacco control policies, which take into account socioeconomic position.

  • 14. Mackenbach, J. P.
    et al.
    Kulhánová, I.
    Menvielle, G.
    Bopp, M.
    Borrell, C.
    Costa, G.
    Deboosere, P.
    Esnaola, S.
    Kalediene, R.
    Kovacs, K.
    Leinsalu, M.
    Martikainen, P.
    Regidor, E.
    Rodriguez-Sanz, M.
    Strand, B. H.
    Hoffmann, R.
    Eikemo, T. A.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Mid-Sweden University , Sweden.
    Trends in inequalities in premature mortality: a study of 3.2 million deaths in 13 European countries2015In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 69, no 3, p. 207-217Article in journal (Refereed)
    Abstract [en]

    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.

  • 15. Mackenbach, Johan P.
    et al.
    Kulhánová, Ivana
    Artnik, Barbara
    Bopp, Matthias
    Borrell, Carme
    Clemens, Tom
    Costa, Giuseppe
    Dibben, Chris
    Kalediene, Ramune
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Mid Sweden University, Sweden.
    Martikainen, Pekka
    Menvielle, Gwenn
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Prochorskas, Remigijus
    Rodríguez-Sanz, Maica
    Heine Strand, Bjørn
    Looman, Caspar W. N.
    de Gelder, Rianne
    Changes in mortality inequalities over two decades: register based study of European countries2016In: BMJ Open, E-ISSN 2044-6055, Vol. 353, article id 1732Article in journal (Refereed)
    Abstract [en]

    Objective To determine whether government efforts in reducing inequalities in health in European countries have actually made a difference to mortality inequalities by socioeconomic group.

    Design Register based study.

    Data source Mortality data by level of education and occupational class in the period 1990-2010, usually collected in a census linked longitudinal study design. We compared changes in mortality between the lowest and highest socioeconomic groups, and calculated their effect on absolute and relative inequalities in mortality (measured as rate differences and rate ratios, respectively).

    Setting All European countries for which data on socioeconomic inequalities in mortality were available for the approximate period between years 1990 and 2010. These included Finland, Norway, Sweden, Scotland, England and Wales (data applied to both together), France, Switzerland, Spain (Barcelona), Italy (Turin), Slovenia, and Lithuania.

    Results Substantial mortality declines occurred in lower socioeconomic groups in most European countries covered by this study. Relative inequalities in mortality widened almost universally, because percentage declines were usually smaller in lower socioeconomic groups. However, as absolute declines were often smaller in higher socioeconomic groups, absolute inequalities narrowed by up to 35%, particularly among men. Narrowing was partly driven by ischaemic heart disease, smoking related causes, and causes amenable to medical intervention. Progress in reducing absolute inequalities was greatest in Spain (Barcelona), Scotland, England and Wales, and Italy (Turin), and absent in Finland and Norway. More detailed studies preferably using individual level data are necessary to identify the causes of these variations.

    Conclusions Over the past two decades, trends in inequalities in mortality have been more favourable in most European countries than is commonly assumed. Absolute inequalities have decreased in several countries, probably more as a side effect of population wide behavioural changes and improvements in prevention and treatment, than as an effect of policies explicitly aimed at reducing health inequalities.

  • 16. Mackenbach, JP
    et al.
    Kulhanova, I
    Bopp, M
    Deboosere, P
    Eikemo, TA
    Hoffmann, R
    Kulik, MC
    Leinsalu, M
    Martikainen, P
    Menvielle, G
    Regidor, E
    Wojtyniak, B
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Mid-Sweden University, Sweden.
    Variations in the relation between education and cause-specific mortality in 19 European populations: A test of the “fundamental causes” theory of social inequalities in health2015In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 127, p. 51-62Article in journal (Refereed)
    Abstract [en]

    Link and Phelan have proposed to explain the persistence of health inequalities from the fact that socioeconomic status is a “fundamental cause” which embodies an array of resources that can be used to avoid disease risks no matter what mechanisms are relevant at any given time. To test this theory we compared the magnitude of inequalities in mortality between more and less preventable causes of death in 19 European populations, and assessed whether inequalities in mortality from preventable causes are larger in countries with larger resource inequalities.

    We collected and harmonized mortality data by educational level on 19 national and regional populations from 16 European countries in the first decade of the 21st century. We calculated age-adjusted Relative Risks of mortality among men and women aged 30–79 for 24 causes of death, which were classified into four groups: amenable to behavior change, amenable to medical intervention, amenable to injury prevention, and non-preventable.

    Although an overwhelming majority of Relative Risks indicate higher mortality risks among the lower educated, the strength of the education–mortality relation is highly variable between causes of death and populations. Inequalities in mortality are generally larger for causes amenable to behavior change, medical intervention and injury prevention than for non-preventable causes. The contrast between preventable and non-preventable causes is large for causes amenable to behavior change, but absent for causes amenable to injury prevention among women. The contrast between preventable and non-preventable causes is larger in Central & Eastern Europe, where resource inequalities are substantial, than in the Nordic countries and continental Europe, where resource inequalities are relatively small, but they are absent or small in Southern Europe, where resource inequalities are also large.

    In conclusion, our results provide some further support for the theory of “fundamental causes”. However, the absence of larger inequalities for preventable causes in Southern Europe and for injury mortality among women indicate that further empirical and theoretical analysis is necessary to understand when and why the additional resources that a higher socioeconomic status provides, do and do not protect against prevailing health risks.

  • 17. Metsä-Simola, Niina
    et al.
    Heggebø, Kristian
    Kjaer Urhoj, Stine
    Martikainen, Pekka
    Einiö, Elina
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Neurological conditions and subsequent divorce risk in the Nordic countries: the importance of gender and both spouses’ education2024In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738Article in journal (Refereed)
    Abstract [en]

    Background Prior studies suggest that poor physical health, accompanied by functional disability, is associated with increased divorce risk. However, this association may depend on gender, the socioeconomic resources of the couple, as well as the social policy and social (in)equality context in which the illness is experienced. This study focuses on neurological conditions, which often have substantial functional consequences.

    Methods We used longitudinal population-wide register data from the years 2007–2016 (Denmark, Sweden) or 2008–2017 (Finland, Norway) to follow 2 809 209 married couples aged 30–64 for neurological conditions, identified using information on specialised healthcare for diseases of the nervous system and subsequent divorce. Cox regression models were estimated in each country, and meta-analysis used to calculate across-country estimates.

    Results During the 10-year follow-up period, 22.2% of couples experienced neurological conditions and 12.0% of marriages ended in divorce. In all countries, divorce risk was elevated among couples where at least one spouse had a neurological condition, and especially so if both spouses were ill. The divorce risk was either larger or similar for husband’s illness, compared with wife’s illness, in all educational categories. For the countries pooled, the weighted average HR was 1.21 (95% CI 1.20 to 1.23) for wives’ illness, 1.27 (95% CI 1.25 to 1.29) for husbands’ illness and 1.38 (95% CI 1.34 to 1.42) for couples where both spouses were ill.

    Conclusions Despite some variation by educational resources and country context, the results suggest that the social consequences of illness are noticeable even in Nordic welfare states, with the husband’s illness being at least as important as the wife’s.

  • 18. Moustgaard, Heta
    et al.
    Tarkiainen, Lasse
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Karolinska Institutet, Sweden.
    Korhonen, Kaarina
    Zangarini, Nicolás
    Costa, Giuseppe
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    The contribution of alcohol-related deaths to the life-expectancy gap between people with and without depression - a cross-country comparison2022In: Drug And Alcohol Dependence, ISSN 0376-8716, E-ISSN 1879-0046, Vol. 238, article id 109547Article in journal (Refereed)
    Abstract [en]

    Background: Alcohol-related deaths may be among the most important reasons for the shorter life expectancy of people with depression, yet no study has quantified their contribution. We quantify the contribution of alcoholrelated deaths to the life-expectancy gap in depression in four European countries with differing levels of alcoholrelated mortality.

    Methods: We used cohort data linking population registers with health-care and death records from Denmark, Finland, Sweden and Turin, Italy, in 1993-2007 (210,412,097 person years, 3046,754 deaths). We identified psychiatric inpatients with depression from hospital discharge registers in Denmark, Finland, and Sweden and outpatients with antidepressant prescriptions from prescription registers in Finland and Turin. We assessed alcohol-related and non-alcohol-related deaths using both underlying and contributory causes of death, stratified by sex, age and depression status. We quantified the contribution of alcohol-related deaths by cause-of-death decomposition of the life-expectancy gap at age 25 between people with and without depression.

    Results: The gap in life expectancy was 13.1-18.6 years between people with and without inpatient treatment for depression and 6.7-9.1 years between those with and without antidepressant treatment. The contribution of alcohol-related deaths to the life-expectancy gap was larger in Denmark (33.6%) and Finland (18.1-30.5%) - i.e., countries with high overall alcohol-related mortality - than in Sweden (11.9%) and Turin (3.2%), and larger among men in all countries. The life-expectancy gap due to other than alcohol-related deaths varied little across countries.

    Conclusions: Alcohol contributes heavily to the lower life expectancy in depression particularly among men and in countries with high overall alcohol-related mortality.

  • 19. Mäki, Netta E.
    et al.
    Martikainen, Pekka T.
    Eikemo, Terje
    Menvielle, Gwenn
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS). Mid Sweden University, Sweden.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Mackenbach, Johan P.
    The potential for reducing differences in life expectancy between educational groups in five European countries: the effects of obesity, physical inactivity and smoking2014In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 68, no 7, p. 653-640Article in journal (Refereed)
    Abstract [en]

    Introduction This study assesses the effects of obesity, physical inactivity and smoking on life expectancy (LE) differences between educational groups in five European countries in the early 2000s. Methods We estimate the contribution of risk factors on LE differences between educational groups using the observed risk factor distributions and under a hypothetically more optimal risk factor distribution. Data on risk factor prevalence were obtained from the Survey of Health, Ageing and Retirement in Europe study, and data on mortality from census-linked data sets for the age between 50 and 79 according to sex and education. Results Substantial differences in LE of up to 2.8 years emerged between men with a low and a high level of education in Denmark, Austria and France, and smaller differences among men in Italy and Spain. The educational differences in LE were not as large among women. The largest potential for reducing educational differences was in Denmark (25% among men and 41% among women) and Italy (14% among men). Conclusions The magnitude of the effect of unhealthy behaviours on educational differences in LE varied between countries. LE among those with a low or medium level of education could increase in some European countries if the behavioural risk factor distributions were similar to those observed among the highly educated.

  • 20. Mäki, Netta
    et al.
    Martikainen, Pekka
    Eikemo, Terje
    Menvielle, Gwenn
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Jasilionis, Domantas
    Mackenbach, Johan P.
    Educational differences in disability-free life expectancy: a comparative study of long-standing activity limitation in eight European countries2013In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 94, p. 1-8Article in journal (Refereed)
    Abstract [en]

    Healthy life expectancy is a composite measure of length and quality of life and an important indicator of health in aging populations. There are few cross-country comparisons of socioeconomic differences in healthy life expectancy. Most of the existing comparisons focus on Western Europe and the United States, often relying on older data. To address these deficiencies, we estimated educational differences in disability-free life expectancy for eight countries from all parts of Europe in the early 2000s. Long-standing severe disability was measured as a Global Activity Limitation Indicator (GALI) derived from the European Union Statistics on Income and Living Conditions (EU-SILC) survey. Census-linked mortality data were collected by a recent project comparing health inequalities between European countries (the EURO-GBD-SE project). We calculated sex-specific educational differences in disability-free life expectancy between the ages of 30 and 79 years using the Sullivan method. The lowest disability-free life expectancy was found among Lithuanian men and women (33.1 and 39.1 years, respectively) and the highest among Italian men and women (42.8 and 44.4 years, respectively). Life expectancy and disability-free life expectancy were directly related to the level of education, but the educational differences were much greater in the latter in all countries. The difference in the disability-free life expectancy between those with a primary or lower secondary education and those with a tertiary education was over 10 years for males in Lithuania and approximately 7 years for males in Austria, Finland and France, as well as for females in Lithuania. The difference was smallest in Italy (4 and 2 years among men and women, respectively). Highly educated Europeans can expect to live longer and spend more years in better health than those with lower education. The size of the educational difference in disability-free life expectancy varies significantly between countries. The smallest and largest differences appear to be in Southern Europe and in Eastern and Northern Europe, respectively.

  • 21.
    Rehnberg, Johan
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Esser, Ingrid
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Interdependent pathways between socioeconomic position and health: A Swedish longitudinal register-based study2021In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 280, article id 114038Article in journal (Refereed)
    Abstract [en]

    Health inequalities are generated by the conditions in which people are born, grow, live, work and age. From a life-course perspective, these conditions are formed by complex causal relationships with mutual and intertwined paths between socioeconomic position and health. This study attempts to disentangle some of these processes by examining pathways between socioeconomic position and health across the life-course. We used yearly Swedish national register data with information from over 31 years for two cohorts born 1941-1945 and 1961-1965. We analyzed associations between several indicators of childhood and adult socioeconomic position and health, measured by number of in-patient hospitalizations. We estimated within- and between-person associations using random intercept cross-lagged panel models. The results showed bi-directional associations between socioeconomic position and health that varied in strength across the life-course. Age variations in the associations were primarily observed when individuals aged into or out of age-stratified institutions. In ages where transitions from education to the labor market are common, the associations from health to income and education were strong. Around and after retirement age, the between-person association from health to income was weak, while the association from income to health strengthened. Within-person estimates showed no association between income and subsequent hospitalization among older persons, indicating no direct causal effect of income change on health in this age group. For persons of middle age, the associations were of similar strength in both directions and present at both the between- and within-person level. Our findings highlight the importance of theoretical frameworks and methods that can incorporate the interplay between social, economic, and biological processes over the life-course in order to understand how health inequalities are generated.

  • 22.
    Rehnberg, Johan
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Fors, Stefan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Region Stockholm, Sweden.
    Fritzell, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Trends in the shape of the income–mortality association in Sweden between 1995 and 2017: a repeated cross-sectional population register study2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 3, article id e054507Article in journal (Refereed)
    Abstract [en]

    Objective We investigate recent trends in income inequalities in mortality and the shape of the association in Sweden. We consider all-cause, preventable and non-preventable mortality for three age groups (30–64, 65–79 and 80+ years).

    Design and setting Repeated cross-sectional design using Swedish total population register data.Participants All persons aged 30 years and older living in Sweden 1995–1996, 2005–2006 and 2016–2017 (n=8 084 620).

    Methods Rate differences and rate ratios for all-cause, preventable and non-preventable mortality were calculated per income decile and age group.

    Results From 1995 to 2017, relative inequalities in mortality by income increased in Sweden in the age groups 30–64 years and 65–79 years. Absolute inequalities increased in the age group 65–79 years. Among persons aged 80+ years, inequalities were small. The shape of the income–mortality association was curvilinear in the age group 30–64 years; the gradient was stronger below the fourth percentile. In the age group 65–79 years, the shape shifted from linear in 1995–1996 to a more curvilinear shape in 2016–2017. In the oldest age group (80+ years), varied shapes were observed. Inequalities were more pronounced in preventable mortality compared with non-preventable mortality. Income inequalities in preventable and non-preventable mortality increased at similar rates between 1995 and 2017.

    Conclusions The continued increase of relative (ages 30–79 years) and absolute (ages 65–79 years) mortality inequalities in Sweden should be a primary concern for public health policy. The uniform increase of inequalities in preventable and non-preventable mortality suggests that a more complex explanatory model than only social causation is responsible for increased health inequalities.

  • 23. van der Wel, Kjetil A.
    et al.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Korhonen, Kaarina
    Martikainen, Pekka
    Nybo Andersen, Anne-Marie
    Kjaer Urhoj, Stine
    A gold mine, but still no Klondike: Nordic register data in health inequalities research2019In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 47, no 6, p. 618-630Article in journal (Refereed)
    Abstract [en]

    Aims: Future research on health inequality relies on data that cover life-course exposure, different birth cohorts and variation in policy contexts. Nordic register data have long been celebrated as a 'gold mine' for research, and fulfil many of these criteria. However, access to and use of such data are hampered by a number of hurdles and bottlenecks. We present and discuss the experiences of an ongoing Nordic consortium from the process of acquiring register data on socio-economic conditions and health in Denmark, Finland, Norway and Sweden. Methods: We compare experiences of data-acquisition processes from a researcher's perspective in the four countries and discuss the comparability of register data and the modes of collaboration available to researchers, given the prevailing ethical and legal restrictions. Results: The application processes we experienced were time-consuming, and decision structures were often fragmented. We found substantial variation between the countries in terms of processing times, costs and the administrative burden of the researcher. Concerned agencies differed in policy and practice which influenced both how and when data were delivered. These discrepancies present a challenge to comparative research. Conclusions: We conclude that there are few signs of harmonisation, as called for by previous policy documents and research papers. Ethical vetting needs to be centralised both within and between countries in order to improve data access. Institutional factors that seem to facilitate access to register data at the national level include single storage environments for health and social data, simplified ethical vetting and user guidance.

  • 24.
    Östergren, O
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Menvielle, G
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Adjustment method to ensure comparability between populations reporting mortality data in different formats in the EURO-GBD-SE project2011Other (Other academic)
  • 25.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Educational inequalities in mortality are larger at low levels of incomeManuscript (preprint) (Other academic)
  • 26.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Educational inequalities in mortality are larger at low levels of income: A register-based study on premature mortality among 2.3 million Swedes, 2006–20092018In: SSM - Population Health, ISSN 2352-8273, Vol. 5, p. 122-128Article in journal (Refereed)
    Abstract [en]

    Education develops skills that help individuals use available material resources more efficiently. When material resources are scarce, each decision becomes comparatively more important. Education may also protect from health-related income decline, since the highly educated tend to work in occupations with lower physical demands. Educational inequalities in health may, therefore, be more pronounced at lower levels of income. The aim of this study is to assess whether the shape of the income gradient in premature mortality depends on the level of education.

    Total population data on education, income and mortality was obtained by linking several Swedish registers. Income was defined as five-year average disposable household income for ages 35–64 and mortality follow-up covered the period 2006–2009. The final population comprised 2.3 million individuals, 6.2 million person-years and 14,362 deaths. Income was modeled using splines in order to allow variation in the functional form of the association across educational categories. Poisson regression with robust standard errors was used.

    The curvilinear shape of the association between income and mortality was more pronounced among those with a low education. Both absolute and relative educational inequalities in premature mortality tended to be larger at low levels of income. The greatest income differences in mortality were observed for those with a low education and the smallest for the highly educated.

    Education and income interact as predictors of mortality. Education is a more important factor for health when access to material resources is limited.

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  • 27.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Growing gaps: the importance of income and family for educational inequalities in mortality among Swedish men and women 1990–20092015In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 43, no 6, p. 563-570Article in journal (Refereed)
    Abstract [en]

    Aims: Although absolute levels of mortality have decreased among Swedish men and women in recent decades, educational inequalities in mortality have increased, especially among women. The aim of this study is to disentangle the role of income and family type in educational inequalities in mortality in Sweden during 1990-2009, focusing on gender differences. Methods: Data on individuals born in Sweden between the ages of 30 and 74 years were collected from total population registries, covering a total of 529,275 deaths and 729 million person-months. Temporary life expectancies (age 30-74 years) by education were calculated using life tables, and rate ratios were estimated with Poisson regression with robust standard errors. Results: Temporary life expectancy improved among all groups except low educated women. Relative educational inequalities in mortality (RRs) increased from 1.79 to 1.98 among men and from 1.78 to 2.10 among women. Variation in family type explained some of the inequalities among men, but not among women, and did not contribute to the trend. Variation in income explained a larger part of the educational inequalities among men compared to women and also explained the increase in educational inequalities in mortality among men and women. Conclusions: Increasing educational inequalities in mortality in Sweden may be attributed to the increase in income inequalities in mortality.

  • 28.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    The social gradient in smoking: individual behaviour, norms and nicotine dependence in the later stages of the cigarette epidemic2022In: Social Theory & Health, ISSN 1477-8211, E-ISSN 1477-822X, no 20, p. 276-290Article in journal (Refereed)
    Abstract [en]

    The cigarette epidemic tends to develop in a similar pattern across diverse populations in different parts of the world. First, the prevalence of smoking increases, then it plateaus and finally it declines. The decline in smoking prevalence tends to be more pronounced in higher social strata. The later stages of the cigarette epidemic are characterized by emerging and persisting socioeconomic gradients in smoking. Due to its detrimental health consequences, smoking has been the subject of extensive research in a broad range of academic disciplines. I draw on literature from both the social and medical sciences in order to develop a model in which physiological nicotine dependence, individual smoking behaviour and norms surrounding smoking in the immediate social environment are related through reflexive processes. I argue that the emergence and persistence of social gradients in smoking at the later stages of the cigarette epidemic can be attributed to a combination of the pharmacological properties of nicotine, network homophily and the unequal distribution of material and non-material resources across social strata.

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  • 29.
    Östergren, Olof
    Stockholm University, Faculty of Social Sciences, Department of Sociology.
    Understanding the Educational Gradient in Mortality2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    There is a positive association between education and longevity. Individuals with a university degree tend to live longer than high school graduates who, in turn, live longer than those with compulsory education. These differences are neither larger nor smaller in Sweden than in other European countries, despite its ambitious welfare-state policies. Furthermore, educational differences in longevity are growing, especially among women.

    In this thesis I look at the structural, individual and behavioral processes which generate and maintain the educational gradient in mortality. This is done by compiling theoretical insights and empirical research from a range of scientific disciplines. In doing so, this thesis aims to contribute to a more comprehensive understanding of the educational gradient in mortality.

    Several factors contribute to the association between education and health. Social and biological processes initiated in early life influence both educational achievement and adult health. Education helps individuals become more effective as agents by fostering generic skills such as information-gathering and decision-making. This aspect of education, learned effectiveness, promotes control and health regardless of available resources and prevailing conditions. Education thus has a direct influence on health. Education also indirectly influences health by giving access to better occupational positions and higher incomes, as well as by promoting social capital and healthy habits.

    The empirical section of the thesis consists of four separate quantitative studies using register data. Three of the studies use Swedish national register data while one uses register data from 18 European populations. The results indicate that widening income inequalities in mortality have contributed to a widening of educational inequalities in mortality, since education is a determinant of income. Both alcohol and smoking contribute to educational inequalities in longevity, but smoking has played an especially pronounced role in the widening of inequalities among women. Smoking represents a significant part of the explanation as to why women with low education have experienced smaller gains in life expectancy than the rest of the population. The results also indicate that the general trend towards more well-educated populations has contributed to the widening educational inequalities in mortality in Europe and that education is a stronger predictor of mortality among low income-earners than among the rest of the population.

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  • 30.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Cederström, Agneta
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Korhonen, Kaarina
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; Max Planck Institute for Demographic Research, Germany.
    Migrant mortality by duration of residence and co-ethnic density-A register-based study on Finnish migrants in Sweden with matched controls in the origin and the destination2023In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 83, article id 103064Article in journal (Refereed)
    Abstract [en]

    Migrant health depends on factors both at the origin and at the destination. Health-related behaviors established before migration may change at the destination. We compare the mortality rates from alcohol- and smokingrelated causes and cardiovascular diseases (CVD) of Finnish migrants in Sweden to matched controls in both Sweden and Finland with similar sociodemographic characteristics. Migrant mortality rates from behavioral risk factors lie in-between the rates of non-migrants in the origin and destination. A longer duration of residence is associated with lower mortality and with mortality patterns more similar to Swedes for men. For women, a longer duration of residence is associated with higher mortality, in particular smoking-related mortality, with no tendency of a gradual convergence. The density of Finnish migrants in the local area is modestly associated with mortality. However, CVD mortality tends to be higher and more similar to the level in Finland for migrants in areas with a higher density of Finnish migrants. The results suggest that behavioral changes can reduce mortality differences between migrants and natives and that this can be either beneficial or detrimental to migrant health.

  • 31.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Fors, Stefan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Region Stockholm, Sweden.
    Rehnberg, Johan
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Excess Mortality by Individual and Spousal Education for Recent and Long-Term Widowed2022In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368, Vol. 77, no 5, p. 946-955Article in journal (Refereed)
    Abstract [en]

    Objectives

    The loss of a spouse is followed by a dramatic but short-lived increase in the mortality risk of the survivor. Contrary to expectations, several studies have found this increase to be larger among those with high education. Having a spouse with high education is associated with lower mortality, which suggests that losing a spouse with high education means the loss of a stronger protective factor than losing a spouse with low education. This may disproportionately affect the high educated because of educational homogamy.

    Methods

    We use Swedish total population registers to construct an open cohort of 1,842,487 married individuals aged 60–89 during 2007–2016, observing 239,276 transitions into widowhood and 277,946 deaths. We use Poisson regression to estimate relative and absolute mortality risks by own and spousal education among the married and recent and long-term widows.

    Results

    We find an absolute increase in mortality risk, concentrated to the first 6 months of widowhood across all educational strata. The relative increase in mortality risk is larger in higher educational strata. Losing a spouse with high education is associated with higher excess mortality, which attenuates this difference.

    Discussion

    When considering the timing and the absolute level of excess mortality, we find that the overall patterns of excess mortality are similar across educational strata. We argue that widowhood has a dramatic impact on health, regardless of education.

  • 32.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Korhonen, Kaarina
    Gustafsson, Nina-Katri
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Home and away: mortality among Finnish-born migrants in Sweden compared to native Swedes and Finns residing in Finland2021In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 31, no 2, p. 321-325Article in journal (Refereed)
    Abstract [en]

    Background: Most first-generation migrants have lower mortality compared to the native population. Finnish-born migrants in Sweden instead have higher mortality; possibly because of health behaviours established before migration. To increase our understanding of this excess mortality, we compared the cause-specific mortality of Finnish migrants in Sweden to both the native population of Sweden and the native Finnish population residing in Finland.

    Methods: We used Swedish and Finnish register data, applying propensity score matching techniques to account for differences in sociodemographic characteristics between the migrants, Swedes and Finns. The index population were Finnish migrants aged 40–60, residing in Sweden in 1995. We compared patterns of all-cause, alcohol- and smoking-related, and cardiovascular disease mortality across the groups in the period 1996–2007.

    Results: Finnish migrant men in Sweden had lower all-cause mortality compared to Finnish men but higher mortality compared to the Swedish men. The same patterns were observed for alcohol-related, smoking-related and cardiovascular disease mortality. Among women, all three groups had similar levels of all-cause mortality. However, Finnish migrant women had higher alcohol-related mortality than Swedish women, similar to Finnish women. Conversely, migrant women had similar levels of smoking-related mortality to Swedish women, lower than Finnish women.

    Conclusions: Finnish-born migrants residing in Sweden have mortality patterns that are typically in between the mortality patterns of the native populations in their country of origin and destination. Both the country of origin and destination need to be considered in order to better understand migrant health.

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  • 33.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Artnik, Barbara
    Bopp, Matthias
    Borrell, Carme
    Kalediende, Ramune
    Leinsalu, Mall
    Martikainen, Pekka
    University of Helsinki, Finland.
    Regidor, Enrique
    Rodríguez-Sanz, Maica
    de Gleder, Rianne
    Mackenbach, Johan P.
    Educational expansion and inequalities in mortality — A fixed-effects analysis using longitudinal data from 18 European populations2017In: PLOS ONE, E-ISSN 1932-6203, Vol. 12, no 8, article id e0182526Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this paper is to empirically evaluate whether widening educational inequalities in mortality are related to the substantive shifts that have occurred in the educational distribution.Materials and methods: Data on education and mortality from 18 European populations across several decades were collected and harmonized as part of the Demetriq project. Using a fixed-effects approach to account for time trends and national variation in mortality, we formally test whether the magnitude of relative inequalities in mortality by education is associated with the gender and age-group specific proportion of high and low educated respectively.Results: The results suggest that in populations with larger proportions of high educated and smaller proportions of low educated, the excess mortality among intermediate and low educated is larger, all other things being equal.Conclusion: We conclude that the widening educational inequalities in mortality being observed in recent decades may in part be attributed to educational expansion.

  • 34.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, Pekka
    University of Helsinki, Finland.
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Centre for Health Equity Studies (CHESS).
    The contribution of alcohol consumption and smoking to educational inequalities in life expectancy among Swedish men and women during 1991–20082018In: International Journal of Public Health, ISSN 1661-8556, E-ISSN 1661-8564, Vol. 63, no 1, p. 41-48Article in journal (Refereed)
    Abstract [en]

    Objectives

    To assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden.

    Methods

    We used register data on the Swedish population at ages 30–74 during 1991–2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality.

    Results

    Alcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking.

    Conclusions

    Smoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.

  • 35.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Martikainen, Pekka
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). University of Helsinki, Finland; The Max Planck Institute for Demographic Research, Germany.
    Tarkiainen, Lasse
    Elstad, Jon Ivar
    Brønnum-Hansen, Henrik
    Contribution of smoking and alcohol consumption to income differences in life expectancy: evidence using Danish, Finnish, Norwegian and Swedish register data2019In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 73, no 4, p. 334-339Article in journal (Refereed)
    Abstract [en]

    Background Despite being comparatively egalitarian welfare states, the Nordic countries have not been successful in reducing health inequalities. Previous studies have suggested that smoking and alcohol contribute to this pattern. Few studies have focused on variations in alcohol-related and smoking-related mortality within the Nordic countries. We assess the contribution of smoking and alcohol to differences in life expectancy between countries and between income quintiles within countries.

    Methods We collected data from registers in Denmark, Finland, Norway and Sweden comprising men and women aged 25–79 years during 1995–2007. Estimations of alcohol-related mortality were based on underlying and contributory causes of death on individual death certificates, and smoking-related mortality was based on an indirect method that used lung cancer mortality as an indicator for the population-level impact of smoking on mortality.

    Results About 40%–70% of the between-country differences in life expectancy in the Nordic countries can be attributed to smoking and alcohol. Alcohol-related and smoking-related mortality also made substantial contributions to income differences in life expectancy within countries. The magnitude of the contributions were about 30% in Norway, Sweden and among Finnish women to around 50% among Finnish men and in Denmark.

    Conclusions Smoking and alcohol consumption make substantial contributions to both between-country differences in mortality among the Nordic countries and within-country differences in mortality by income. The size of these contributions vary by country and sex.

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  • 36.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Pekka, Martikainen
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. University of Helsinki, Finland .
    The contribution of smoking-related deaths to the gender gap in life expectancy in Sweden between 1997 and 20162020In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 48, no 3, p. 346-349Article in journal (Refereed)
    Abstract [en]

    Aims: In recent decades, smoking-related mortality has declined among men and increased among women in Sweden. We estimate the contribution of smoking-related deaths to the narrowing of the gender gap in life expectancy in Sweden between 1997 and 2016.

    Methods: We extracted population data on deaths and population under risk on the entire Swedish population aged 25 years and over for the period 1997–2016. Smoking-related mortality was assessed using an indirect method based on lung cancer mortality. We then estimated the contribution of smoking to the gender gap in life expectancy by comparing the observed life expectancies to life expectancies excluding smoking-related deaths.

    Results: The gender gap in life expectancy was 5.0 years in 1997 and 3.4 years in 2016. The gender gap narrowed by 1.6 years, of which 0.6 years were attributable to smoking-related deaths.

    Conclusions: The combination of decreasing smoking-related mortality among men and increasing smoking-related mortality among women in Sweden accounted for almost 40% of the narrowing of the gender gap in life expectancy during the period 1997–2016.

  • 37.
    Östergren, Olof
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Rehnberg, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Lundberg, Olle
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Miething, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    Disruption and selection: the income gradient in mortality among natives and migrants in Sweden2023In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 33, no 3, p. 372-377Article in journal (Refereed)
    Abstract [en]

    Background 

    The income gradient in mortality is generated through an interplay between socio-economic processes and health over the life course. International migration entails the displacement of an individual from one context to another and may disrupt these processes. Furthermore, migrants are a selected group that may adopt distinct strategies and face discrimination in the labour market. These factors may have implications for the income gradient in mortality. We investigate whether the income gradient in mortality differs by migrant status and by individual-level factors surrounding the migration event.

    Methods

    We use administrative register data comprising the total resident population in Sweden aged between 30 and 79 in 2015 (n = 5.7 million) and follow them for mortality during 2015-17. We estimate the income gradient in mortality by migrant status, region of origin, age at migration and country of education using locally estimated scatterplot smoothing and Poisson regression.

    Results

    The income gradient in mortality is less steep among migrants compared with natives. This pattern is driven by lower mortality among migrants at lower levels of income. The gradient is less steep among distant migrants than among close migrants, migrants that arrived as adults compared with children and migrants that received their education in Sweden as opposed to abroad.

    Conclusions

    Our results are consistent with the notion that income inequalities in mortality are generated through life-course processes that may be disrupted by migration. Data restrictions prevent us from disentangling life-course disruption from selection into migration, discrimination and labour market strategies.

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