Socioeconomic inequalities in smoking-attributable mortality in Europe; understanding trends 2000-2020 21 2 Introduction Ever since the Black-report in 1980, many strategies have been proposed to combat socioeconomic inequalities in health.1 Health inequalities however remained persistent throughout Europe, with socioeconomically more advantageous groups living longer and in better health.2 One of the most important behavioural factors contributing to socioeconomic inequalities in life expectancy is smoking.3 Patterns in smoking and smoking related mortality have often been described using the tobacco epidemic model. This model consists of four stages in which smoking rates among men initially increased and then began to decline following the increase in smoking-related mortality. Among women, a similar pattern is observed, but lagged in time and with a less extreme peak in smoking prevalence.4, 5 Prevalence rates not only differ by sex, but also between countries and socioeconomic groups,6, 7 and individual smoking behaviour is in part determined by social factors that change over time. For example, smoking is influenced by gender norms,8 and while the male-female smoking ratio has decreased, smoking prevalence has a negative educational gradient for both genders.9 Whereas smoking was initially primarily adopted among higher educated individuals, it has become more prevalent among lower educated individuals.10 In the past 20 years, smoking patterns in Europe have changed tremendously and are declining overall, 11, 12 which can in part be attributed to tobacco control measures.13 In Europe, the Tobacco Control Scale (TCS) quantifies the stringency of the implementation of tobacco control policies and has been shown at the ecological level to be associated with a lower prevalence of smoking and higher quit rates over the last decade.13 However, tobacco control measures are unlikely to decrease socioeconomic inequalities, except for price increases.14 Most tobacco control policies are aimed at smoking reduction in the general population and not focussed on decreasing inequalities. In an evaluation of 27 European countries, tobacco control policies were associated with smoking cessation among individuals with a higher socioeconomic position but not among those with a lower socioeconomic position.15 Given the developments in smoking behaviour and tobacco control policies, it is likely that educational inequalities in smoking-attributable mortality are changing as well, although with a delay. A wide range of studies investigated the role of smoking in educational differences in different European countries.16-18 Comparing several countries with different social, economic and political structures will allow countries to learn from each other, which can help to inform health policy and recommendations.
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