Elsevier

Lung Cancer

Volume 63, Issue 3, March 2009, Pages 322-330
Lung Cancer

Socioeconomic inequalities in lung cancer mortality in 16 European populations

https://doi.org/10.1016/j.lungcan.2008.06.006Get rights and content

Abstract

Objectives

This paper aims to describe socioeconomic inequalities in lung cancer mortality in Europe and to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in overall mortality and smoking within the same or reference populations. Particular attention is paid to inequalities in Eastern European and Baltic countries.

Methods

Data were obtained from mortality registers, population censuses and health interview surveys in 16 European populations. Educational inequalities in lung cancer and total mortality were assessed by direct standardization and calculation of two indices of inequality: the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). SIIs were used to calculate the contribution of inequalities in lung cancer mortality to inequalities in total mortality. Indices of inequality in lung cancer mortality in the age group 40–59 years were compared with indices of inequalities in smoking taking into account a time lag of 20 years.

Results

The pattern of inequalities in Eastern European and Baltic countries is more or less similar as the one observed in the Northern countries. Among men educational inequalities are largest in the Eastern European and Baltic countries. Among women they are largest in Northern European countries. Whereas among Southern European women lung cancer mortality rates are still higher among the high educated, we observe a negative association between smoking and education among young female adults. The contribution of lung cancer mortality inequalities to total mortality inequalities is in most male populations more than 10%. Important smoking inequalities are observed among young adults in all populations. In Sweden, Hungary and the Czech Republic smoking inequalities among young adult women are larger than lung cancer mortality inequalities among women aged 20 years older.

Conclusions

Important socioeconomic inequalities exist in lung cancer mortality in Europe. They are consistent with the geographical spread of the smoking epidemic. In the next decades socioeconomic inequalities in lung cancer mortality are likely to persist and even increase among women. In Southern European countries we may expect a reversal from a positive to a negative association between socioeconomic status and lung cancer mortality. Continuous efforts are necessary to tackle socioeconomic inequalities in lung cancer mortality in all European countries.

Introduction

Lung cancer in Europe is still the most common cancer related cause of death with an estimated 334,800 deaths (19.7% from total cancer mortality) in 2006 [1]. Even though lung cancer mortality in men has been declining since the late 1980s, female lung cancer mortality is still increasing in many European countries [2], [3]. Trends also show important country variations [4].

Some studies have assessed socioeconomic inequalities in overall mortality and cause-specific mortality in a range of European countries [5], [6]. The relationship between lung cancer mortality and socioeconomic status has also been investigated in several individual countries, both in Europe [7], [8], [9] and elsewhere [10], [11]. In most countries a low education was found to be an independent risk factor for lung cancer and/or lung cancer mortality. One study conducted a systematic analysis of variations between countries in the size and pattern of socioeconomic inequalities in lung cancer mortality, using data from 10 European populations, collected in the first half of the 1990s [12]. The study demonstrated consistently higher lung cancer mortality rates among the “lower” educated men and women in Northern and Western Europe and an inverse or less pronounced socioeconomic gradient in some Southern European populations.

As lung cancer continues to be an unabated pandemic, further research of inequalities in lung cancer mortality remains an important issue.

Even though previous cross-European studies have put into evidence an important north–south gradient in socioeconomic inequalities both in lung cancer mortality and smoking [12], [13], and related this to the theory of the smoking epidemic [14], there is need to focus further on regional differences in lung cancer mortality inequalities in Europe by including also Eastern European and Baltic countries. One particular point of interest is to find out if the smoking epidemic in Eastern European countries spreads through populations in a similar way as is the case in other European countries. As studies on socioeconomic inequalities in smoking have now been published for over two decades and recommendations to tackle inequalities in smoking have been suggested [15], there is also need to verify if there are any indications that inequalities in lung cancer mortality in Europe will in the future decrease, or on the contrary, will continue to persist.

In this paper we present new European results on socioeconomic inequalities in lung cancer mortality, based on recent and extensive datasets, collected in 16 European populations. More specifically the objectives of the paper are: (1) to describe socioeconomic inequalities in lung cancer mortality in a wide range of European population groups, including Eastern and Central European countries; (2) to assess the contribution of lung cancer to inequalities in total mortality; (3) to get further insight into socioeconomic inequalities in lung cancer mortality in different European populations by relating these to socioeconomic inequalities in smoking practices within the same or reference populations.

Cigarette smoking is indeed the major cause of lung cancer, and most lung cancers have historically occurred among current cigarette smokers or recent quitters. As population patterns in smoking prevalence will continue to be the most powerful predictor of the future occurrence of lung cancer [16], smoking data could give clues about the future evolution of socioeconomic inequalities in lung cancer mortality. In some birth cohorts also other environmental and occupational factors may have contributed to the present international patterns of socioeconomic differences in lung cancer mortality. In such case the relation between lung cancer mortality inequalities and former smoking inequalities may be less clear-cut.

Knowledge on the contribution of lung cancer to inequalities in total mortality is important to identify populations in which a reduction of the inequalities in lung cancer mortality will also have a substantial impact on inequalities in total mortality. Previous research has shown that the contribution of lung cancer mortality to the difference between manual and non-manual classes in total mortality varies substantially from one country to another [17]. This study allowed us to investigate the impact of lung cancer mortality on the overall socioeconomic inequalities in mortality with another socioeconomic measure and in a larger number of countries.

The study was conducted in the framework of the EUROTHINE project2 that aimed to help policy-makers at the European and national level to develop rational strategies for tackling socioeconomic inequalities in health. Global results of this project, based on international comparisons of socioeconomic inequalities in mortality and morbidity in many European countries, have been presented elsewhere [18].

Section snippets

Data

Data on lung cancer mortality, total mortality and socioeconomic status were available for 16 countries or regions, including 4 Eastern European and 2 Baltic countries. Table 1 describes the data sources and some characteristics of the data collection. Most data sources were situated at the national level, but also regional and big urban populations (Basque Country, Barcelona, Madrid, Turin) were included. The majority of networks provided longitudinal data. In Barcelona a record linkage was

Results

In the 16 studied populations the age adjusted lung cancer mortality rates in the age group 40–79 years ranged from 65.8/100,000 person years in Sweden to 252.4/100,000 person years in Hungary among men, and from 11.9/100,000 person years in Madrid to 76.4/100,000 person years in Denmark among women.

Table 3 presents age adjusted lung cancer mortality rates by level of education for men and women in different age groups. Among men we observed a sharp increase in lung cancer mortality with a

Summary of findings

Our study indicates that there are still important socioeconomic inequalities in lung cancer mortality in Europe. Some regional patterns can be distinguished. Large socioeconomic inequalities, with much higher lung cancer mortality rates among the low educated, are observed in the male populations of some Eastern European countries, like the Czech Republic and Hungary. Among women the largest inequalities in lung cancer mortality are observed in the Northern populations. In most populations

Conflict of interest statement

None declared.

Acknowledgements

We wish to thank the European Commission that through the Public Health Program financed the Eurothine project (grant agreement 2003125). We also thank all the study sites that provided data, as well as all partners and international experts who have contributed to this EC project.

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